Handbook of Clinical Geropsychology

Handbook of
Clinical Geropsychology
The Plenum Series in Adult Development and Aging
SERIES EDITOR:
Jack Demick, Suffolk University, Boston, Massachusetts
ADULT DEVELOPMENT, THERAPY, AND CULTURE

A Postmodern Synthesis
Gerald D. Young
THE AMERICAN FATHER

Biocultural and Developmental Aspects
Wade C. Mackey
THE DEVELOPMENT OF LOGIC IN ADULTHOOD

Postformal Thought and Its Applications
Jan D. Sinnott
HANDBOOK OF AGING AND MENTAL HEALTH

An Integrative Approach
Edited by Jacob Lomranz
HANDBOOK OF CLINICAL GEROPSYCHOLOGY

Edited by Michel Hersen and Vincent B. Van Hasselt
HANDBOOK OF PAIN AND AGING

Edited by David 1. Mostofsky and Jacob Lomranz
HUMAN DEVELOPMENT IN ADULTHOOD

Lewis R. Aiken
PSYCHOLOGICAL TREATMENT OF OLDER ADULTS
An Introductory Text
Edited by Michel Hersen and Vincent B. Van Hasselt
Handbook of
Edited by
Michel Hersen
Pacific University
Forest Grove, Oregon
and
Vincent B. Van Hasselt
Nova Southeastern University
Fort Lauderdale, Florida
Springer Science+Business Media, LLC

Library of Congress C a t a l o g i n g - i n - P u b l i c a t i o n Data
Handbook of c l i n i c a l geropsycho logy / e d i t e d by Michel Hersen and

Vincent B. Van H a s s e l t .
p. cm. — (The Plenum s e r i e s in a d u l t development and aging)
I n c l u d e s b i b l i o g r a p h i c a l r e f e r e n c e s and index.
1. G e r i a t r i c p s y c h i a t r y — H a n d b o o k s , manuals, e t c . 2. Aged--Mental
h e a l t h — H a n d b o o k s , manuals, e t c . 3. C l i n i c a l psychology—Handbooks,
manuals, e t c . I . Hersen, Michel. I I . Van H a s s e l t , Vincent B.
III. Series.
[DNLM: 1. Mental D i s o r d e r s — i n old age. 2. Mental D i s o r d e r s -
-therapy. 3. G e r i a t r i c Psych i a t r y — m e t h o d s . 4. Aged—psycho logy .
WT 150 H23441 1998]
RC451.4.A5H356 1998
618.97*689—dc21
DNLM/DLC
f o r L i b r a r y of Congress 98-21527
CIP
ISBN 978-1-4899-0132-3 ISBN 978-1-4899-0130-9 (eBook)

DOI 10.1007/978-1-4899-0130-9
© Springer Science+Business Media New York 1998

Originally published by Plenum Press, New York in 1998
Softcover reprint of the hardcover 1st edition 1998
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Contributors
RONALD D. ADELMAN, Division of Geriatrics and Gerontology, New York Hospi-

tal-Cornell Medical Center, New York, New York 10021
PATRICIA A. AREAN, Department of Psychiatry, University of California-San Fran-

cisco, San Francisco, California 94143-0984
J. GAYLE BECK, Department of Psychology, State University of New York, Buffalo,

New York 14260
STEPHEN J. BARTELS, Department of Psychiatry and Community and Family Med-

icine, New Hampshire-Dartmouth Psychiatric Research Center, Dartmouth
Medical School, Concord, New Hampshire 03301
GARY R. BIRCHLER, Department of Psychiatry, School of Medicine, University of

California, San Diego, La Jolla, California 92093-0603
FRANCE C. BLAIS, Ecole de Psychologie, Universite Laval, Cite Universitaire,

Quebec, Canada G1K 7P4
LOUIS D. BURGIO, Center for Aging, Division of Gerontology and Geriatric Medi-
cine, and Department of Psychology, University of Alabama at Birmingham,
Birmingham, Alabama 35294-4410
TONY CELLUCCI, Department of Psychology, Francis Marion University, Florence,

South Carolina 29501-0547
KATIE E. CHERRY, Department of Psychology, Louisiana State University, Baton

Rouge, Louisiana 70803-5501
ANTONIA CHRONOPOLOUS, Center for Psychological Studies, Nova Southeastern

University, Fort Lauderdale, Florida 33314
JOAN M. COOK, Center for Psychological Studies, Nova Southeastern University,

Fort Lauderdale, Florida 33314
DAVID W. COON, Older Adult Center, Veterans Affairs Health Care System, Palo
Alto, California 94304
v
vi Contributors
ELLEN M. CorrnR, Center for Aging, Division of Gerontology and Geriatric Medi-
cine, and Department of Psychology, University of Alabama at Birmingham,
Birmingham, Alabama 35294-4410
PATRICK H. DELEON, Administrative Assistant to U.S. Senator Daniel K. Inouye,
U.S. Senate, Hart Senate Building, Washington, D.C. 20510-1102
LARRY W. DUPREE, Department of Aging and Mental Health, The Florida Mental
Health Institute, University of South Florida, Tampa, Florida 33612-3899
BUNNY FALK, Center for Psychological Studies, Nova Southeastern University,
Fort Lauderdale, Florida 33314
WILLIAM FALS-STEWART, Department of Psychology, Old Dominion University,
Norfolk, Virginia 23529-0267
NANCY FOLDI, Division of Neurology, Winthrop-University Hospital, Mineola,
New York 11501
MARY J. GAGE, Mellon Center, Cleveland Clinic, Cleveland, Ohio 44195
DOLORES GALLAGHER-THOMPSON, Older Adult Center, Veterans Affairs Health Care
System, Palo Alto, California 94304 and Stanford University School of Medi-
cine, Stanford, California
CHARLES J. GOLDEN, Center for Psychological Studies, Nova Southeastern Uni-
versity, Fort Lauderdale, Florida 33314
ANTHONY J. GORECZNY, Director of Clinical Training Program, Department ofPsy-
chology, University ofIndianapolis, Indianapolis, Indiana 46227-3697
IGOR GRANT, Department of Psychiatry, School of Medicine, University of Cali-
fornia, San Diego, La Jolla, California 92093-0680
CHERYL BURNS HARDISON, Program for Research on Black Americans, Institute for
Social Research, University of Michigan, Ann Arbor, Michigan 48106-1248
MICHEL HERSEN, School of Professional Psychology, Pacific University, Forest
Grove, Oregon 97116
JAMES S. JACKSON, Program for Research on Black Americans, Institute for Social
Research, University of Michigan, Ann Arbor, Michigan 48106-1248
MICHAEL LAVIN, Department of Psychology, University of Arizona, Tucson, Ari-
zona 85721
HOWARD D. LERNER, Department of Psychology, University of Michigan, Ann Ar-
bor, Michigan 48104
EDITH S. LISANSKy-GOMBERG, Alcohol Research Center, Department of Psychology,
University of Michigan, Ann Arbor, Michigan 48104
NATHANIEL MCCONAGHY, Psychiatric Unit, Prince of Wales Hospital, Randwick
2031, New South Wales, Australia
Contributors vii
KEITH M. MILES, Department of Psychiatry and Community and Family Medi-
cine, New Hampshire-Dartmouth Psychiatric Research Center, Dartmouth Med-
ical School, Concord, New Hampshire 03301
VERONIQUE MIMEAULT, Ecole de Psychologie, Universite Laval. Cite Universitaire,
CHARLES M. MORIN, Ecole de Psychologie, Universite Laval. Cite Universitaire,
DEBRA S. MORLEY, Department of Psychology, Boston University, Boston, Massa-
chusetts 02215
DAVID I. MOSTOFSKY, Laboratory for Experimental Behavioral Medicine, Depart-
ment of Psychology, Boston University, Boston, Massachusetts 02215
KIM T. MUESER, Department of Psychiatry and Community and Family Medicine,
New Hampshire-Dartmouth Psychiatric Research Center, Dartmouth Medical
School, Concord, New Hampshire 03301
TED D. NIRENBERG, Department of Psychiatry and Human Behavior, and Center
for Alcohol and Addiction Studies, Brown University, and Department of Emer-
gency Medicine, Rhode Island Hospital, Providence, Rhode Island 02908
THOMAS L. PATTERSON, Department of Psychiatry, School of Medicine, University
of California, San Diego, La Jolla, California 92093-0680
DAVID POWERS, Older Adult Center, Veterans Affairs Health Care System, Palo
PETER V. RAsINs, Department of Psychiatry and Behavioral Sciences, Johns Hopkins
University School of Medicine, Baltimore, Maryland 21287-7279
PATRICIA RIvERA, Older Adult Center, Veterans Affairs Health Care System, Palo
BRUCE D. SALES, Department of Psychology, University of Arizona, Tucson, Ari-
zona 85721
DEREK SATRE, Department of Psychiatry, University of California-San Francisco,
San Francisco, California 94143-0984
LAWRENCE SCHONFELD, Department of Aging and Mental Health, The Florida Men-
tal Health Institute, University of South Florida, Tampa, Florida 33612-3899
DANIEL L. SEGAL, Department of Psychology, University of Colorado at Colorado
Springs, Colorado Springs, Colorado 80933-7150
SHERRILL L. SELLERS, Program for Research on Black Americans, Institute for So-
cial Research, University of Michigan, Ann Arbor, Michigan 48106-1248
SHIRLEY SEMPLE, Department of Psychiatry, School of Medicine, University of
viii Contributors
WILLIAM S. SHAW, Department of Psychiatry, School of Medicine, University of

HENNA SIDDIQUI, Division of Geriatrics, Winthrop-University Hospital, Mineola,
New York 11501
ANDERSON D. SMITH, School of Psychology, Georgia Institute of Technology, At-
lanta, Georgia 30332-0001
MELINDA A. STANLEY, Department of Psychiatry and Behavioral Sciences, Uni-
versity of Texas Mental Sciences Institute, Health Science Center at Houston,
Houston, Texas 77030
WARREN W. TRYON, Department of Psychology, Fordham University, Bronx, New
York 10458-5198
HEATHER UNCAPHER, Department of Psychiatry, University of California-Berkeley,
Berkeley, California 94720
VINCENT B. VAN HASSELT, Center for Psychological Studies, Nova Southeastern
University, Fort Lauderdale, Florida 33314
GARY R. VANDENBos, American Psychological Association, Washington, D.C.
20002-4242
PATRICIA A. WISOCKI, Department of Psychology, University of Massachusetts,
Amherst, Massachusetts 01003
ANTONETTE M. ZEISS, Training and Program Development, Psychology Service,
and Interprofessional Team Training and Development Program, Older Adult
Center, Veterans Affairs Health Care System. Palo Alto, California 94304
Preface
Clinical psychology is a relatively young profession, with its major growth

spurt having occurred in the period after World War II. Clinical geropsychology,
a subspecialty of clinical psychology, is of most recent vintage, with its growth
spurt paralleling the dramatic increase in older adults in the United States. In-
deed, in the past two decades the number of persons over 65 years of age has in-
creased by 65%. In the year 2030, one third ofthe population is projected to be
55 years of age and older. In addition, the number of very old (Le., those more
than 85 years of age) is expected to increase by a factor of 6 by the middle of the
next century.
Given this so-called graying of America, it should not be surprising that
clinical psychologists have turned their attention to the assessment and reme-
diation of the problems that are faced (and will continue to be faced) by our se-
nior citizens. It is paradoxical that despite our aging population and increased
longevity, the age designated as the beginning of study for geropsychology has
decreased from 65 to 55, and in some instances even 50. Also of interest are the
changes in terminology with respect to study of older individuals, going from
the more pejorative geriatrics, to the less pejorative gerontology, to clinical
geropsychology, which now reflects the work of clinical psychologists. Editors
of other handbooks have used the words aging and gerontology in their titles.
This is the first compendium referred to as the Handbook of Clinical Psychol-
ogy and it, of course, highlights the contributions of clinical psychology.
The Handbook of Clinical Geropsychology contains 25 chapters divided into
three parts. In Part I ("General Issues"), in addition to a historical perspective, the
chapters are about clinical geropsychology and U.S. federal policy, psychody-
namic issues, the values of behavioral perspectives in treating older adults, moral
and ethical considerations in geropsychology, and normal memory aging.
Part II ("Psychopathology, Assessment, and Treatment") incorporates de-
scription, assessment, and treatment for dementia, substance abuse disorders,
schizophrenia, depression, anxiety disorders, sexual dysfunction, sleep distur-
bances in late life, personality disorders, aging and mental retardation, and be-
havioral medicine interventions with older adults.
Finally, in Part m("Special Issues"), nine problem areas faced by older adults
and their caregivers are given consideration, including health and well-being in
retirement, pain management, the experience of bereavement by older adults,
marriage and divorce, family caregiving, prevention, minority issues, physical ac-
tivity, and approaches to diagnosis and treatment of elder abuse and neglect.
ix
x Preface
We anticipate that this book will be of interest to professionals and stu-

dents from a wide range of disciplines, including psychology, psychiatry, reha-
bilitation, education, social work, and nursing, especially given the explosion
of new data in this area. Not only is there academic interest in the area of clini-
cal geropsychology, but growing media and governmental attention has focused
on the shift in the age spectrum of the population in our country, with its at-
tendant problems. Given the new data and the increasing population of older
people, we believe that a new handbook in the field of clinical geropsychology
is indeed warranted, especially one that presents coverage of issues from the
perspective of clinical psychology.
As an a priori apologia, we should note that in light of the newness of clin-
ical geropsychology, the conclusions reached in some of the chapters can only
be described as tentative. In some instances, there may be greater attention fo-
cused on where the field is going. Perhaps more definitive statements will ap-
pear in future editions of this work, as necessary.
Many individuals have contributed to the genesis and fruition of this proj-
ect. First, we thank our editor and friend at Plenum Press, Eliot Werner, who
understood the merits ofthis endeavor. Second, we thank our contributors who
took time out to share their expertise with us. And finally, we thank our friend,
Burt G. Bolton, who graciously has provided us with his technical expertise.
Michel Hersen
Vincent B. Van Hasselt
Contents
PART I. GENERAL ISSUES
1. Historical Perspectives 3
Joan M. Cook, Michel Hersen, and Vincent B. Van Hasselt
2. Clinical Geropsychology and U.S. Federal Policy 19
Gary R. VandenBos and Patrick H. DeLeon
3. Psychodynamic Issues 29
Howard D. Lerner
4. The Value of Behavioral Perspectives in Treating Older Adults 51
Larry W. Dupree and Lawrence Schonfeld
5. Moral and Ethical Considerations in Geropsychology 71
Michael Lavin and Bruce D. Sales
6. Normal Memory Aging 87
Katie E. Cherry and Anderson D. Smith
PART II. PSYCHOPATHOLOGY, ASSESSMENT. AND TREATMENT
7. Dementia 113
Charles J. Golden and Antonia Chronopolous
8. Substance Abuse Disorders 147
Ted D. Nirenberg, Edith S. Lisansky-Gomberg, and Tony Cellucci
9. Schizophrenia 173
Stephen J. Bartels, Kim T. Mueser, and Keith M. Miles
10. Depression 195
Patricia A. Arean, Heather Uncapher, and Derek Satre
11. Anxiety Disorders 217
Melinda A. Stanley and J. Gayle Beck
12. Sexual Dysfunction 239
Nathaniel McConaghy
xi
xii Contents
13. Sleep Disturbances in Late Life 273

Charles M. Morin, France C. Blais, and Veronique Mimeault
14. Personality Disorders 301
Bunny Falk and Daniel L. Segal
15. Aging and Mental Retardation 323
Ellen M. Cotter and Louis D. Burgio
16. Behavioral Medicine Interventions with Older Adults 351
Mary J. Gage and Anthony J. Goreczny
PART III. SPECIAL ISSUES
17. Health and Well-Being in Retirement: A Summary of Theories

and Their Implications 383
William S. Shaw, Thomas L. Patterson. Shirley Semple. and Igor Grant
18. Pain Management 411
Debra S. Morley and David 1. Mostofsky
19. The Experience of Bereavement by Older Adults 431
Patricia A. Wisocki
20. Marriage and Divorce 449
Gary R. Birchler and William Fals-Stewart
21. Family Caregiving: Stress, Coping, and Intervention 469
Dolores Gallagher-Thompson. David W. Coon. Patricia Rivera. David
Powers, and Antonette M. Zeiss
22. Prevention 495
Peter V. Rabins
23. Minority Issues 505
Sherrill L. Sellers. James S. Jackson. and Cheryl Burns Hardison
24. Physical Activity 523
Warren W. Tryon
25. Approaches to Diagnosis and Treatment of Elder Abuse
and Neglect 557
Ronald D. Adelman, Henna Siddiqui. and Nancy Foldi
Subject Index 569
PART I
GENERAL ISSUES
CHAPTER 1
Historical Perspectives
JOAN M. COOK, MICHEL HERSEN,
AND VINCENT B. VAN HASSELT
INTRODUCTION
A review of the historical perspectives of geropsychology reveals a remarkable

progression in standpoints on aging. The development in knowledge of aging is
substantial and has been rapidly increasing in recent years. This chapter provides
a historical review of the growth and development of the scientific psychological
study of older adults. In the first section, we examine why there is a growing in-
terest in the psychology of older individuals. In the second section, we examine
the historical antecedents of geropsychology, ranging over three time periods:
1835 to 1918,1919 to 1946, and 1947 to the present. Although most of the histor-
ical antecedents section focuses on perspectives on psychological research on
older adults, information on policy and practice in geropsychology is added
where deemed necessary. The last section of this chapter focuses on future per-
spectives in the field of geropsychology. It is important to understand that re-
search, policy, and practice on aging depends in part on contextual variables such
as social, economic, and political influences (Riegel, 1973).
AN INCREASING INTEREST IN
PSYCHOLOGY OF AGING
In the latter half of the 20th century, there are more older persons than there
have been at any other time throughout history (Dychtwald & Flower, 1989). From
1900 to 1990, the percentage of older people (65 years and over) in the population
grew from 4% to 13%, while the proportion of young people (under 18 years) has
diminished from 40% to 26% (U.S. Department of Health and Human Services,
JOAN M. COOK AND VINCENf B. VAN HASSELT • Center for Psychological Studies, Nova Southeastern
University. Fort Lauderdale. Florida 33314. MICHEL lIERsEN • School of Professional Psychol-
ogy. Pacific University. Forest Grove. Oregon 97116.
3
4 Joan M. Cook et a1.
1995). The unprecedented shift in the relative age group composition of society
can be explained in part by vastly improved medical technology and care.
Contrary to popular opinion and media depiction, the elderly are not a ho-
mogeneous group. Approaches to aging must take into account the hetero-
geneity of older adults especially with respect to physical health, cognitive
functioning, and gender. Demographic projections show that our population is
changing dramatically in terms of age, ethnic, and cultural composition. For ex-
ample, the oldest old, persons over the age of 85 years, are the fastest-growing
segment of the aged population (Suzman, Willis. & Manton, 1992). In addition.
there is a coming wave of aging "baby boomers." Further, in the next 50 years.
the nonwhite portion of the elderly population is anticipated to nearly double
(Angel & Hogan, 1994). In particular, according to Jackson (1988), the African
American population is growing at a faster rate than any other older group.
With the dramatic increase in the population surviving to old age, the num-
ber of individuals at risk for physical, social, economic. and mental problems
has also increased. Indeed. aging has often been synonymous with inevitable
loss: loss of spouse, friends, and relatives, loss of work and decreased income.
loss of acuity in sensory modalities. and lessening of physical abilities and cog-
nitive functioning.
Variables under study in the field of geropsychology are wide-ranging.
Psychological theories of aging address broad areas such as personality, intel-
ligence, problem solving, sensation, perception, memory. and life satisfaction.
The study of emotional well-being and social and independent functioning in
older adults provides an objective basis for establishing the general experi-
ences of older adults. Psychologists studying aging also concentrate on specific
areas such as pain, insomnia, and incontinence. The behavioral functioning
of an aging population includes normative aspects and deviations in the aging
process.
Mental health disorders in the elderly have also received attention in the
literature. As the population over 65 increases, psychological stress and mental
disorders will become an increasingly important public health issue. As men-
tally ill persons continue to "age in place," it is imperative to assess and meet
their service needs (Holhouser. 1988). Compounding the impact of mental ill-
ness are medical and social comorbidities: As the severely mentally ill age,
their comorbid medical diagnoses multiply (Kramer, 1983) and mentally ill el-
derly are less likely to receive needed physical and mental health services than
are younger persons (German, Shapiro, & Skinner, 1985). Approximately half of
the older adult population who received care for physical disorders also had at
least one mental disorder. Unrecognized and untreated psychopathology in
conjunction with medical illness and functional difficulties place the elderly at
increased risk for hospitalization and long-term institutionalization. Further,
lack of appropriate diagnosis and treatment often leads to a decline in essential
self-sustaining activities that are key determinants of quality of life.
As the number of elderly persons increases, there is an escalating need for
mental health care and social services. Currently, there is a shortage of persons
who research and provide services to aging individuals, particularly those
highly qualified in the behavioral and mental health sciences and services. Al-
though the field of psychology of aging has a substantial number of excellent re-
Historical Perspectives 5
searchers and clinicians examining significant problems, more educational pro-

grams and incentives are needed to train and encourage people in such careers.
Despite a strong and active field of psychology and aging, there are obvious
omissions and deficiencies. For example, research on and services for special
groups of elderly individuals who are at increased risk for experiencing psy-
chological and psychopathologic difficulties are lacking. Groups especially at
increased risk for interpersonal and intrapersonal complications are the chron-
ically mentally ill who survive into old age, older individuals with mental re-
tardation, and those living below poverty levels in public housing.
HISTORICAL ANTECEDENTS
As far back as ancient times, philosophers have discussed unique features

among individuals of different ages. In fact, many philosophers have concerned
themselves with defining a good old age. In the past, individuals who survived
to old age were fairly rare.
Since few people survived to old age, myths were formulated to account for
such occurrences. Human beings who lived for long periods of time were hy-
pothesized to be favored by the gods or were suspected of ingesting special
herbs. Fascinated with the idea of rejuvenation, Ponce de Leon searched for the
Fountain of Youth in Florida. In the hope of discovering ways to increase the
lifespan, Francis Bacon observed the aging population, speculating that im-
provements in hygiene would reduce germs and disease and subsequently in-
crease chances of survival. Benjamin Franklin was another investigator of aging
who searched for the answer to the rejuvenation myth. He erroneously specu-
lated that with use of electricity deceased humans could be resurrected.
Until the early 20th century, life expectancy was relatively short (i.e., 45
years at the beginning ofthis century). Disease, famine, and war are among the
variables associated with a limited life span. The study of aging has a long past,
but a short history. It was not until comparatively recent times that scientists be-
gan formally to study aging.
Years 1835 to 1918
The origin of the study of the psychology of aging is often credited to Lam-
bert Adolphe Jacques Quetelet (Birren, 1961). Quetelet, a mathematician and
astronomer, initiated the first collection of psychological data in examining hu-
man development and aging. In his book On Man and the Development of His
Faculties, published in 1835, Quetelet presented his data on sensory function-
ing, height, weight, hand strength, and productivity across various age groups
(Riegel, 1977).
The next leading researcher interested in the scientific study of aging was
Sir Francis Galton (Birren, 1961). In the 1880s, Galton collected data from 9,337
males and females, 5 to 80 years old, who visited the London International
Health Exhibitions. In his anthropometric laboratory, he employed standard-
ized instruments to measure the degree of association of certain variables with
6 Joan M. Cook et a1.
aging (including sensorimotor performance). Indeed, Galton was the first scien-
tist to conclude on an empirical basis that most human capacities tend to de-
cline as they age. These findings, published in 1885, established Galton as the
founder of the psychology of individual and developmental differences.
Simultaneously, the first psychological laboratory was founded by Wilhelm
Wundt in Leipzig, Germany. Wundt's physiological experiments also increased
our knowledge about geropsychology. However, his students required almost a
decade to become fully aware of the discrepancies in performance between sub-
jects of different ages (Birren, 1961).
In Russia, Ivan Pavlov was also studying the connections between physi-
ology and psychology. His studies had further implications for an evolving psy-
chology of aging field. In particular, Pavlov's finding that the conditioning of
older animals was different from that of younger animals was pivotal in estab-
lishing the importance of developmental differences (Riegel, 1977).
Years 1919 to 1946
Although largely ignored by fellow researchers, Foster and Taylor (1920)

investigated differential changes in intellectual functioning of adults, including
the aged. They examined the relationship of speed, functioning, and demographic
variables such as educational level and socioeconomic factors to changes in
intelligence.
In 1922, G. Stanley Hall, primarily known for his work on childhood and
adolescence, published a book entitled Senescence: The Second Half of Life.
This seminal work was a review of the empirical studies of aging, including
psychological, biological, behavioral, and physiological perspectives. Although
his review documented the status of research on aging then current, it also in-
dicated how sparse the geropsychology literature was compared to the child
psychology literature. In addition, Hall was concerned with the relationship be-
tween religious belief and fear of death.
Contemporaries of Hall who were also publishing on aging included biolo-
gists. In 1908, Minot's The Problems of Age, Growth and Death and Metch-
nikoff's The Prolongation of Life were both concerned with explaining aging
relative to an accumulation of bacteria in the gastrointestinal tract and its be-
lieved remedy of ingesting yogurt. In addition, Pearl's (1922) Biology of Death
basically stated that aging was caused and affected by heredity alone. At this
juncture, individuals investigating aging issues had a more experimental ap-
proach and were more physiologically than socially oriented.
Interestingly, at the beginning of the 20th century, as scholars were recog-
nizing the need for the scientific study of the aged, most clinicians were unwill-
ing to extend psychological treatment to older adults. In fact, in the early years
of psychoanalysis, Freud was very skeptical, believing that psychological treat-
ment of individuals over the age of 50 would be ineffective (Freud, 1904/1959).
Freud offered several reasons to substantiate his beliefs: older individuals have
limitations in ego or intellect; analysis would have to cover a relatively longer
lifetime and thus treatment would be prolonged indefinitely; and analysis would
occur at a time when it was no longer important to be psychologically healthy.
In the clinical domain, Abraham (1919/1927) was the first psychoanalyst to

recognize and express optimism for the psychoanalytic treatment of older
adults. He described successful analyses of four older neurotic patients. His
conclusions were critical. Abraham believed that the age at which the older
adult started psychoanalysis or resolution of conflict was less important than
the age of patient at the time the neurosis began.
Although Freud's views on older adults was typical of clinical thinking, pi-
oneer Dr. Lillien Martin eagerly administered psychotherapy to the aged (Mar-
tin, 1944). In 1929, Dr. Martin founded and directed the San Francisco Old Age
Counseling Center. This was the first established psychotherapeutic program
for the aged in the United States. Dr. Martin's therapeutic techniques centered
on overcoming pessimism by adopting the "will-to-do-attitude."
Concurrently, but on the research end, Walter Miles was interested in study-
ing the problems of older workers in industry. He expanded his interests and, in
1928, with the assistance of his colleagues at Stanford University, developed a
project to analyze psychological aspects of aging. Miles's initial findings from
this study, named the Stanford Later Maturity Project, were published in 1931.
Although the significance of this contribution to the study of intellectual devel-
opment has been questioned, it undoubtedly deserves credit as one of the first
studies for breadth in approach and use of experimental methods (Riegel, 1977).
Most early psychological research on adult development and aging was de-
voted to the study of intelligence. For example, Jones and Conrad (1933) ad-
ministered the Army Alpha Test to an adult sample to test for developmental
differences in intellectual functions; cohort differences and historical changes
were examined.
Importantly, at this time, the notion was spreading that disciplines inter-
ested in the scientific study of aging should not be independent and unrelated.
During the 1930s, the Macy Foundation developed an interest in supporting
studies of aging, with an emphasis on interdisciplinary collaboration. The foun-
dation sponsored a conference at Woods Hole, Massachusetts, where re-
searchers with medical, social, psychological, psychiatric, and humanistic
approaches met. In fact, it was the Macy Foundation that encouraged Cowdry
(1939) to include multidisciplinary perspectives in his book entitled Problems
of Aging. Indeed, Miles published some of his data from the Stanford Later Ma-
turity Project in the first chapter of Cowdry's book. This book was a milestone,
in that it brought together the ideas of several disciplines.
Sidney Pressey (1939) was the first psychologist to publish a book on de-
velopment that encompassed adulthood and aging. Pressey, who taught at the
department of psychology at the University of Ohio, trained many Ph.D. candi-
dates with a focus on aging.
Despite the previously mentioned researchers' interest in and experimen-
tation with older adults, the field of geropsychology remained in its infancy. Be-
yond the individuals mentioned previously, few scholars paid attention to
aging until after World War II. Relatively little scientific investigation of aging
and only sporadic public concern for aging issues were evident at this time.
Prior to World War II, the predominant view held by psychology was that child-
hood was an end product rather than part of the course of an ongoing life. The
belief that adolescence represented the final stage of development was widely
8 Joan M. Cook et al.
held. Accordingly, the belief at the time was that there was little to investigate
scientifically postadolescence.
World War II interrupted and curtailed the emerging interest in geropsy-
chology. However, several studies conducted during this time found that per-
formance of American servicemen was greatly affected by age. In the late 1930s,
the surgeon general of the U.S. Public Health Service created a gerontological
unit ofthe National Institute of Health. In 1941, Nathan Shock became the sec-
ond director of this organization, and he brought to the task a psychological as
well as a biological agenda. Subsequently, James Birren became associated with
this group and guided its psychological research.
After World War II, the field of psychology and aging was subjected to more
systematic investigation. The number of scientists interested in studying devel-
opmental and aging processes increased dramatically. These investigators em-
phasized that development and aging continue throughout the adult period.
In 1942, the American Geriatrics Society was established: the society pub-
lishes a journal that bears the same name. The Gerontological Society of Amer-
ica (GSA), a multidisciplinary association, was founded in 1945 (Adler, 1958).
This organization publishes The Journals of Gerontology and The Gerontologist,
two leading journals in the field of aging. In 1946, the American Psychological
Association (APA) added a new division to its structure, Division 20, Maturity
and Old Age (now renamed Division on Adult Development and Aging)
(Pressey, 1948). The field of geropsychology gained power and momentum as
psychologists acquired section representation in a multidisciplinary organiza-
tion (GSA) and an independent group status within a major psychological or-
ganization, the American Psychological Association.
Although Kaplan published Mental Disorders of Later Life in 1945, the
study of the psychopathology of later life grew relatively slowly. One reason for
the lack of emphasis in this area may be stereotypes of mental illness. Although
historically the mentally ill, in general, have not been treated well by society,
older adults with mental health problems appear to have fared even more poorly.
Years 1947 to the Present
The International Association of Gerontology (lAG) was established in

1950. The first meeting of the lAG was primarily focused on biological pro-
cesses of aging. However, in 1953, at the second lAG meeting, a large number of
research papers were presented in the area of geropsychology. To help organize
the wealth of information from journal articles, books, and scientific meetings,
Nathan Shock (1951,1957,1963) started producing A Classified Bibliography of
Gerontology and Geriatrics.
The first book on geropsychology published by the American Psychologi-
cal Association was Anderson's (1956) Psychological Aspects of Aging. In 1959,
Birren's Handbook of Aging and the Individual organized the scattered litera-
ture on the psychology of aging.
Despite the new data adduced, few recognized the impact that the increas-
ing number of older adults would have on our society. Adult development tra-
ditionally was studied with a cross-sectional method, with measurements made
at approximately the same time on subjects differing in chronological age. Re-

searchers in the field of child development were the first to recognize limita-
tions of cross-sectional analyses, and in the early part of the 20th century
initiated longitudinal studies. Nearly 30 years later, scientists involved with ag-
ing research recognized the necessity of conducting longitudinal studies in
adults. Most of the resulting studies, however, emphasized physiological func-
tions and only a few studies included behavioral or personality characteristics.
In the absence of an established comprehensive theoretical paradigm for
normative aging, empirical identification of aspects of aging in community set-
tings was warranted. Beginning in 1955 at Duke University Medical Center's de-
partment of psychiatry, under the leadership of Ewald Busse (1970), a
longitudinal study was conducted to explore physical, mental, and social
processes of normal aging. Community-residing males and females, 60 years
and older, were subjects of the study. One area of inquiry focused on character-
izing behavioral correlates of changes in the aging central nervous system. An-
other broad area of interest concerned the adaptive aspects of behavior studied
within a social psychological framework (Siegler, 1983). A significant finding
from the study was that a substantial number of participants did not show de-
cline in intellectual function. Evidence that most older people maintained high
levels of cognitive functioning confirmed the notion that intellectual decline
was not an inevitable concomitant of aging. In 1968, a second longitudinal
study at Duke, known as the Duke Adaptation Study, was initiated. This study
focused on the short- and long-term effects of stressful life events (death of
spouse, retirement). One of the most important findings under the rubric of psy-
chological inquiry was that adult personality showed little change over the
eight years ofthe study. A third longitudinal study of aging, entitled Mental Ill-
ness and Social Support Among the Very Old, was conducted at Duke.
Yet another longitudinal study that has had a tremendous impact on cur-
rent theorizing on aging processes is the Baltimore Longitudinal Study of Aging
(BLSA) (Shock et aI., 1984). The Duke studies included participants 60 years
or older; the BLSA examined healthy aging over the entire adult life span (17
years and above). In addition, the Duke studies consisted ofthree separate stud-
ies in which data collection has been completed, whereas the BLSA data collec-
tion remains in progress. Beginning in 1958, participants in the BLSA were given
repeated tests and examinations over their life span, including inquiries on cog-
nitive performance, personality, and stress and coping processes. Findings from
this study stress the many individual differences in the experience of aging.
There is a great range of variation in psychological indicators in community-
residing adults.
In the early 1960s, the National Institutes of Health (NIH) funded several
programs at universities to aid scientists in the formation of systematic studies
on aging. These universities included the University of Chicago, the University
of Michigan-Wayne State University Institute of Gerontology, and the Ethel
Percy Andrus Gerontology Center at the University of Southern California. The
gerontological institutes promoted exchange of ideas and thus contributed sub-
stantially to development of the field of geropsychology.
In particular, at the University of Chicago's Committee on Human Devel-
opment, under the aegis of Robert Havighurst and Bernice Neugarten, doctoral
level students were trained in the social psychology of aging. In fact, some of
the most significant contributions to the social psychology of aging came from
this department (Neugarten, 1968). Indeed, the Kansas City Studies of Adult
Life, conducted by University of Chicago researchers, greatly advanced knowl-
edge on normal personality development in adulthood. In particular, research
on ego styles and sex-role changes in middle age and later adulthood was
greatly emphasized.
In 1961, the first White House Conference on Aging (WHCoA) was con-
vened. This represented the first national symposium, joining members of the
scientific, clinical, and lay communities in a productive public exchange on
the elderly. By 1965, the United States Congress established Medicare and the
Older Americans Act (OAA). The OAA was the first program to focus on com-
munity-based services for older adults. Two of the objectives of this Act were
that the federal, state, and local governments assist older adults in obtaining
mental health care and institutional, home, and community long-term care.
During the 1960s, there was a rapid expansion in the number of publica-
tions in psychological gerontology. One landmark study conducted during this
period focused on life span developmental changes in intelligence (Schaie,
1965). Data collection began in 1956 for the Seattle Longitudinal Studies (SLS);
the study is still in progress (Schaie, 1993). Information from the SLS on indi-
vidual variation in the life course of adult intellectual abilities has been widely
disseminated and its impact on the field of psychology and gerontology has
been far-reaching.
Erikson (1963) proposed a theory of psychosocial development that in-
cluded eight major crises an individual faces in the course of a lifetime. This
theory, an alternative to Freud's psychosexual stages of human development,
was the first of its kind to include phases of adult development. Recognition of
developmental tasks and conflicts older individuals face was an important
precedent to the increased interest in treating older adults with psychotherapy.
In the late 1960s and early 1970s, innovative psychiatric programs such as the
Langley Porter Neuropsychiatric Institute and the San Francisco Geriatric
Screening Project encouraged older patients in the community to take advan-
tage of services available for the detection and treatment of mental disorders in
late life (Feigenbaum, 1973; Lowenthal, Berkman, & Associates, 1967).
However, despite a handful of resourceful psychiatric programs, the over-
all mental health service and delivery system for older adults was deficient. In
the 1960s, deinstitutionalization of state psychiatric facilities was imple-
mented. A study of patients in public hospitals estimated that one third of these
residents were 65 or older and that 27% of first admissions were also in this age
group (American Psychiatric Association, 1959). After deinstitutionalization,
adequate care for most of the residents was not provided, and many elderly in
these facilities consequently became residents of nursing homes. Thus, progress
in mental health services for older adults did not keep pace with scientific
progress in this field.
The second White House Conference on Aging was held in 1971. Sub-
sequently, results of psychological investigations that were presented at the
WHCoA and recommendations made by a task force organized by the Amer-
ican Psychological Association were compiled in a book. This second book on
geropsychology issued by the APA was Eisdorfer and Lawton's (1973) The Psy-
chology of Adult Development and Aging.
During the 1960s and 1970s, substantial data in geropsychology were being
adduced. In 1973, Riegel categorized nine common areas of geropsychological
investigation that emphasized cognitive variables: (1) intellectual deterioration,
(2) general intellectual changes, (3) vocabulary performance, (4) verbal skills, (5)
psychomotor skills, (6) short-term retention, (7) dichotic listening, (8) adjust-
ment, and (9) social variables (Poon, 1980).
Subsequently, reviews of the trends and developments in the psychology of
aging became more frequent. For instance, in the late 1970s, a review of the
clinical psychology of aging, a topic that previously had received little atten-
tion, was published (Storandt, Siegler, & Elias, 1979). Another prime chronicle
was entitled Annual Review of Gerontology and Geriatrics (Eisdorfer, 1980).
When the American Psychological Association's third book on geropsychology,
Aging in the 1980's: Psychological Issues, was published, it constituted evi-
dence that the field of geropsychology had advanced and diversified, covering
a wide range of topics from neuropsychological and psychopharmacological is-
sues to environmental and interpersonal concerns (Poon, 1980).
Again, despite advancement of geropsychological science, fragmentation of
clinical services was evident. In response to underutilization of community
mental health centers by older adults, the Community Mental Health Centers
Act of 1963, which declared access to mental health services a civil right, was
amended. In 1975, this amendment mandated special services for older men-
tally ill individuals. Despite such legislation, Gatz, Smyer, and Lawton (1980)
concluded that there was a failure of the mental health system to adequately
provide services to older adults. One reason for this gap between postulated
need and service may be that throughout the 1960s to the 1980s, Medicare, the
national health insurance for older adults, provided little coverage for outpa-
tient services for older adults living in the community (Gatz & Smyer, 1992).
These authors concluded that despite adjustments in federal and state funding
and innovative demonstrations of service, there have been only minimal im-
provements in the mental health system for older adults.
Many federal agencies and departments support aging-related research. Since
1965, the Administration on Aging has developed and coordinated research and
service for older adults. Research on the psychology of the aged has further been
supported by the National Institute on Aging (NIA) since 1974, and the National
Institute of Mental Health (NIMH) since 1960. In addition, in the 1960s, as the age
characteristics of the veteran population increased, the Veterans Administration
(VA) began more actively participating in research projects on aging (Coppinger,
1967). While NIA and NIMH support intramural and extramural research on ag-
ing, the VA supports only intramural research. In 1975 the VA established eight
geriatric research, educational, and clinical centers (GRECCs) across the country,
most of which are involved in geropsychological research. Even though alloca-
tions for behavioral and social science research on aging across all agencies have
increased, the biological sciences garner the lion's share of funding.
The third White House Conference on Aging was held in 1981, with the
theme "The Aging Society: Challenge and Opportunity." National aging popu-
lation dilemmas discussed have included life, expectancy, health, and social
12 Joan M. Cook et 01.
isolation. One of the recommendations from this WHCoA was to increase the
availability of home- and community-based health care and to develop and pro-
mote effective programs for preventive health care (White House Conference on
Aging, 1981).
Approaches for studying development progressed from cross-sectional to
longitudinal and time lag designs. Schaie (1988) concludes that research method-
ology and statistics have had a tremendous impact on theorizing about aging.
With availability of new techniques in statistical analysis, in particular confirma-
Table 1-1. List of Current Journals in Geropsychology

Title Year first published
Journals of Gerontology 1946

Journal of the American Geriatrics Society 1953
Gerontologist 1960
Experimental Gerontology 1965
Journal of Geriatric Psychiatry 1967
Age and Ageing 1972
International Journal of Aging and Human Development 1973
Experimental Aging Research 1975
Journal of Ethnogerontology 1975
Journal of Gerontological Nursing 1975
Educational Gerontology 1976
Clinical Gerontologist 1977
Death Studies 1977
Journal of Gerontological Social Work 1978
Journal of Clinical and Experimental Gerontology 1979
Research on Aging 1979
Journal of Nutrition for the Elderly 1980
Activities, Adaptation and Aging 1980
Gerontology and Geriatrics Education 1980
Physical and Occupational Therapy in Geriatrics 1980
Aging and Society 1981
Geriatric Nursing 1981
Canadian Journal of Ageing 1982
Journal of Applied Gerontology 1982
Geriatrics 1984
Alzheimer Disease and Associated Disorders 1986
American Journal of Alzheimer's Care and Related Disorders and Research 1986
International Journal of Geriatric Psychiatry 1986
Journal of Cross-Cultural Gerontology 1986
Psychology and Aging 1986
Journal of Aging Studies 1988
Journal of Geriatric Psychiatry and Neurology 1988
Archives of Gerontology and Geriatrics 1989
International Psychogeriatrics 1989
Journal of Aging and Health 1989
Behavior, Health, and Aging 1990
Dementia 1990
American Journal of Geriatric Psychiatry 1993
Journal of Adult Development 1993
Education and Aging 1994
Journal of Clinical Geropsychology 1995
Journal of Men tal Health and Aging 1995
tory factor analyses, possibilities for studying various aspects of gerontology have
increased considerably.
As journals in the field of gerontology have proliferated from the 1970s
through the 1990s, the number of journals focusing on or including psycholog-
ical aspects of aging has grown (see Table 1-1). In particular, in 1985 the Amer-
ican Psychological Association established the journal Psychology and Aging.
Another timely journal, inaugurated in 1995, is the Journal of Clinical Geropsy-
chology which focuses on clinical issues.
In 1995, the fourth White House Conference on Aging was held, with the
theme "America Now and Into the 21st Century: Generations Aging Together
with Independence, Opportunity, and Dignity." In addition to discussing the
needs of older Americans, the conference provided an intergenerational per-
spective on aging including multigenerational relationships. Emphasis was
placed on the importance of a comprehensive life span developmental psy-
chology that, of course, includes old age. Researchers and clinicians were en-
couraged to evaluate the organization of behaviors of adults not only at the end
of life, but across the whole life span. Further resolutions from the conference
included meeting mental health care needs and increasing federal funding for
research in aging (diseases of older persons, long-term care, and special popu-
lations) (White House Conference on Aging, 1995).
FUTURE PERSPECTIVES
A sketch of the history of psychology and aging as it has evolved since 1835
has been provided. A more comprehensive description of major studies in psy-
chology and aging from 1884 through 1965 has been reported elsewhere by
Riegel (1973, 1977), who indicated that psychological gerontology has, in part,
recapitulated the history of psychology in general. First, geropsychological
studies focused on sensation and perception. The next general area of explo-
ration was in psychophysics and psychomotor abilities. Later, geropsychology
became concerned with the concept of personality, and eventually the social
psychology of aging was explored.
Since the 1800s, geropsychology has grown and diversified greatly. Its bur-
geoning is most evident in the organizations, associations, conferences, and
journals focusing on or devoted to this field. Psychology has continuing contri-
butions to make to the research and service fields of aging. Although it is es-
sential to gather information on the field of geropsychology, it is equally
imperative to provide directions for the future.
Despite exponential growth of research in psychology and aging, much of this
research involves disparate studies on narrowly defined variables. Birren (1989)
stated that the field of geropsychology is data-rich and theory-poor. He further ar-
gued that the accumulated information on geropsychology is organized by mi-
crotheories. Although previous data can serve as a guideline, at the same time
such information may be viewed as a constraint. A more comprehensive under-
standing of the older person would greatly benefit from an integration of concepts.
Several areas of psychological inquiry warrant further investigation in
older adults. One area is the standardization of assessment in older adults. In
particular, the discrimination of diagnostic procedures in assessing subtypes

within a mental disorder and the comorbidity of disorders require our careful
scrutiny. Understanding clusters of symptoms within a mental disorder of the
elderly may raise questions about the symptoms used in their nomenclature.
Further, symptom correlates that are unique to each disorder may identify fac-
tors that will help improve the differential diagnosis and in turn aid in the
recognition of these disorders.
Further, researchers must examine and combat reasons for the low num-
bers of older adults seen in the current system of mental health care services.
One reason may be the reluctance of some older adults to seek psychological
services. For the elderly who are unwilling or unable to receive care in tradi-
tional settings, it is crucial to learn how to better deliver mental health care.
One service delivery approach is the PATCH (Psychogeriatric Assessment and
Treatment in City Housing) outreach model of psychiatric assessment and treat-
ment (Roca, Storer, Robbins, Tlasek, & Rabins, 1990). Implementation and effi-
cacy of this and other such programs have important implications for the
development of service delivery models.
Although prevention programs are not necessarily capable of averting all
old-age psychopathology, their contribution is essential. Primary prevention ef-
forts aimed at avoiding psychopathology in late life are needed as are secondary
and tertiary prevention targeted toward specific disorders that affect the aged. In
particular, prevention of disease may rely on changing behavior (Carstensen,
1988). Behavioral assessment and treatment in older adults can lead to cost-
effective solutions, which are of utmost importance during this time of shrinking
government funds. Certainly, increased understanding of the nature and distrib-
ution of mental health problems in older persons, differences between late-life
and earlier-onset mental disorders. and identification of etiologic and maintain-
ing factors will facilitate developing prevention and treatment interventions.
Another area that warrants further investigation is the efficacy of psy-
chotherapeutic intervention methods with older adults. Lebowitz and Niede-
rehe (1992) noted that, over the past decade. clinical trials of pharmacologic,
psychotherapeutic. and combined treatments have resulted in validated thera-
pies for some disorders. For example, although limited, the data on treatment of
depression in late life are strong and come from a number of clinical trials
(Niederehe, 1994). However, more psychotherapeutic treatment data for the el-
derly are sorely needed.
With increasing numbers of individuals living considerably longer, efforts
should be made not to prolong the years of life per se, but to prolong the years
of healthy living. The issue, of course, is one of improving quality of life.
Clearer delineations of the behavioral capabilities of older adults and of ways to
make better use of their potential are topics worthy of investigation.
Recently. the U.S. Department of Health and Human Services' Task Force
on Aging Research (1995) formulated future directions for research. Several key
areas were proposed for evaluation, including prevalence of alcohol-related
problems, treatment of depression and anxiety, and behavioral symptoms and
functional disability in Alzheimer's disease patients.
With the benefit of hindsight, it is easy to be critical. Prior to the 1970s, re-
search on aging was deficient methodologically. Replication of research on dif-
ferent age cohorts in the same society and on aging populations in different so-
cieties is warranted. The search for more comprehensive explanations of varia-
tions in aging continues. A complex interactional model is needed.
Geropsychology should continue to benefit from multidisciplinary interaction.
Our current viewpoint should emphasize how multiple factors interact to pro-
duce normal and pathological aging.
ACKNOWLEDGMENT. We thank George Neiderehe for his comments on an

earlier draft of this chapter.
REFERENCES
Abraham. K. (1927). The applicability of psycho-analytic treatment to patients at an advanced age.
In D. Bryan & A. Strachey. Trans .. Selected papers on psychoanalysis (pp. 312-317). New
York: Brunner/Mazel. (Original work published 1919.)
Adler. M. (1958). History of the gerontological society. Journal of Gerontology. 13. 94-100.
American Psychiatric Association. (1959). Report on patients over 65 in public mental hospitals.
Washington. DC: Author.
Anderson. J. E. (1956). Psychological aspects of aging. Washington. DC: American Psychological
Association.
Angel, J. 1.. & Hogan. D. P. (1994). The demography of minority aging populations. In Minority el-
ders: Five goals toward building a public policy base. Washington. DC: Gerontological Society
of America.
Birren. J. E. (Ed.). (1959). Handbook of aging and the individual: Psychological and biological as-
pects. Chicago: University of Chicago Press.
Birren. J. E. (1961). A brief history of the psychology of aging. Gerontologist. 1. 69-77. 127-134.
Birren. J. E. (1989). My perspectives on research on aging. In V. 1. Bengston & K. W. Schaie (Eds.),
The course of later life: Research and reflections (pp. 135-149). New York: Springer.
Busse. E. W. (1970). A physiological, psychological and sociological study of aging. In E. Palmore
(Ed.), Normal aging. Durham, NC: Duke University Press.
Carstensen. L. 1. (1988). The emerging field of behavioral gerontology. Behavior Therapy. 19,259-281.
Coppinger. N. W. (1967). Introduction. Gerontologist. 7 (2), 1-2.
Cowdry. E. V. (Ed.). (1939). Problems of ageing. Baltimore: Williams & Wilkins.
Dychtwald. K.. & Flower. J. (1989). Age wave: The challenges and opportunities of an aging Amer-
ica. Los Angeles: Tarcher.
Eisdorfer. C. (1980). Annual review of gerontology and geriatrics. New York: Springer.
Eisdorfer. C.. & Lawton. M, P. (1973). The psychology of adult development and aging. Washing-
ton. DC: American Psychological Association.
Erikson. E. H. (1963). Childhood and society. New York: Norton.
Feigenbaum. E. (1973). Ambulatory treatment of the elderly. In E. W. Busse & E. Pfeiffer (Eds.). Men-
tal illness in later life (pp. 153-166). Washington. DC: American Psychiatric Press.
Foster. J. C.• & Taylor. G. A. (1920). The application of mental tests to persons over 50. Journal of Ap-
plied Psychology. 4. 29-38.
Freud. S. (1959). On psychotherapy. In J. Riviere (Trans.), Collected papers: Volume 1. Early papers
on the history of the psycho-analytic movement (pp. 249-263). New York: Basic Books. (Orig-
inal work published 1904)
Gatz. M .. & Smyer. M. A. (1992). The mental health system and older adults in the 1990·s. American
Psychologist. 47 (6). 741-751.
Gatz. M .• Smyer. M. A .• & Lawton. M. P. (1980). The mental health system and the older adult. In 1.
Poon (Ed.). Aging in the 1980's: Psychological issues (pp. 5-18). Washington. DC: American·
Psychological Association.
German. P. S .• Shapiro. S .. & Skinner. E. A. (1985). Mental health of the elderly: Use of health and
mental health services. Journal of the American Geriatrics Society. 33. 246-252.
Hall. G. S. (1922). Senescence: The second half of life. New York: Appleton.
16 Joan M. Cook et 01.
Holhouser, W. L. (1988). Aging in place: The demographics and service needs of elderly in urban
public housing. Citizens' housing and planning association.
Jackson, J. S. (1988). The Black American elderly: Research on physical and psychological health.
New York: Springer.
Kaplan, O. J. (1945). Mental disorders in later life. Stanford, CA: Stanford University Press.
Kramer, M. (1983). The continuing challenger: The rising prevalence of mental disorders, associated
chronic diseases and disabling conditions. American Journal of Social Psychiatry. 3, 13-24.
Lebowit, B., & Niederehe, G. (1992). Concepts and issues in mental health and aging. In J. E. Birren
& R. B. Sloane (Eds.), Handbook of mental health and aging (2nd ed., pp. 3-26). San Diego,
CA: Academic.
Lowenthal, M. F., Berkman, P., & Associates. (1967). Aging and mental disorder in San Francisco.
San Francisco: Jossey-Bass.
Martin, L. J. (1944). A handbook for old age counselors. San Francisco: Geertz.
Metchnikoff, E. (1908). The prolongation of life. New York: Putnam.
Miles, W. R. (1931). Measures of certain abilities throughout the life span. Proceedings of the Na-
tional Academy of Sciences U.S.A. 17, 627-633.
Minot, C. (1908). The problems of age, growth, and death. New York: Putnam.
Neugarten, B. L. (1968). Middle age and aging. Chicago: University of Chicago Press.
Niederehe, G. T. (1994). Psychosocial therapies with depressed older adults. In L. S. Schneider,
C. F. Reynolds, B. D. Lebowitz, & A. J. Friedhoff (Eds.), Diagnosis and treatment of depression
in late life: Results of the NIH consensus development conference. Washington, DC: American
Psychiatric Press.
Poon, L. W. (1980): Aging in the 1980's: Psychological issues. Washington, DC: American Psycho-
logical Association.
Pressey, S. L. (1939). Life: A psychological survey. New York: Harper.
Pressey, S. L. (1948). The new division on maturity and old age: Its history and potential services.
American Psychologist, 3, 107-109.
Riegel. K. F. (1973). On the history of psychological gerontology. In C. Eisdorfer & M. P. Lawton
(Eds.), The psychology of adult development and aging (pp. 37-68). Washington, DC: Ameri-
can Psychological Association.
Riegel, K. F. (1977). History of psychological gerontology. InJ. E. Birren & K. W. Schaie (Eds.), Hand-
book of the psychology and aging (1st ed., pp. 70-102). New York: Van Nostrand Reinhold.
Roca, R. P., Storer, D. J., Robbins, B. M., Tlasek, M. E., & Rabins, P. V. (1990). Psychogeriatric as-
sessment and treatment in urban public housing. Hospital and Community Psychiatry, 8,
916-920.
Schaie, K. W. (1965). A general model for the study of developmental problems. Psychological Bul-
letin, 64, 92-107.
Schaie, K. W. (1988). The impact ofresearch methodology on theory building in the developmen-
tal sciences. In J. E. Birren & V. L. Bengston (Eds.), Emergent theories of aging (pp. 41-57).
New York: Springer.
Schaie, K. W. (1993). The Seattle longitudinal studies of adult intelligence. Psychological Science,
2 (6),171-175.
Shock, N. W. (1951). A classified bibliography of gerontology and geriatrics. Stanford, CA: Stan-
ford University Press.
ford University Press ..
Shock, N. W., Greulich, R. C., Costa P. T., Jr., Andres, R., Lakatta, E. G., Arenberg, D., & Tobin, J. D.
(1984). Normal human aging: The Baltimore longitudinal study of aging. Washington, DC:
U.S. Government Printing Office.
Siegler, I. C. (1983). Psychological aspects of the Duke Longitudinal Studies. In K. W. Schaie (Ed.),
Longitudinal studies ofpsychological development in adulthood (pp. 136-190). New York:
Guilford.
Storandt, M., Siegler, I. C., & Elias, M. F. (1979). The clinical psychology of aging. New York:
Plenum.
Suzman, R. w., Willis, D. P., & Manton, K. G. (1992). The oldest old. New York: Oxford University
Press.
U.S. Department of Health and Human Services. (1995). The threshold of discovery: Future direc-
tions for research on aging [Reportl. Washington, DC: Task Force on Aging Research.
White House Conference on Aging. (1981). Final report, the 1981 White House Conference on Ag-
ing: Vol. 1. A national policy on aging. Washington, DC: Author.
White House Conference on Aging. (1995). Proposed report: From resolutions to results, the 1995
White House Conference on Aging. Washington, DC: Author.
CHAPTER 2
and u.s. Federal Policy
GARY R. VANDENBos AND PATRICK H. DELEON
INTRODUCTION
The age distribution in American society has changed drastically since 1900
when only one in 25 Americans was age 65 or older. and the average life span
was 47 years. In the year 2000 one in six Americans will be age 65 or older, and
the average life span will exceed 80 (Neugarten & Neugarten. 1989).
Modern clinical psychology emerged shortly after World War II, in large
part in response to initiatives of the federal government growing out of shortage
of mental health professional during the war (Cummings & VandenBos. 1983).
In 1950, only one out of 12 Americans was age 65 or older and the life ex-
pectancy at birth was 68.2 (Bureau of the Census. 1980, pp. 42. 96). Thus, it is
not surprising that clinical geropsychology was not a significant component of
training in clinical psychology in 1950, even though the American Psychologi-
cal Association (APA) Division on Adult Development and Aging (Division 20)
was one of the initial founding divisions ofthe modem APA in 1946. Clinical
geropsychology has had to establish itself within clinical psychology over the
last 50 years, just as aging-related policy issues have needed to seek out their
own unique status within federal policy and federal legislation.
The two most significant federal legislative issues related to interests and
needs of older persons are general income maintenance (e.g., retirement pensions
and disability payments) and reimbursement for health care costs. The latter,
which include cognitive evaluations, neuropsychological evaluations, and psy-
chotherapeutic interventions, are obviously relevant to clinical geropsychology.
The federal coordination of both programs is the responsibility of the Social Se-
curity Administration (SSA).
GARY R. VANDENBos • American Psychological Association. Washington. D.C. 20002-4242
PATRICK H. DELEON • Administrative Assistant to U.S. Senator Daniel K. Inouye. U.S. Senate. Hart
Senate Building. Washington. D.C. 20510-1102.
19
20 Gary R. VandenBos and Patrick H. DeLeon
SOCIAL SECURITY:
A SIXTY·YEAR OVERVIEW
In 1900, most people in the United States lived and worked on farms, and
economic security for the elderly was provided by the extended family. How-
ever, issues of the economic security for the young and the old changed as
America became more industrialized and more people moved to urban settings.
The Great Depression eventually triggered a crisis in the nation's economic life
that influenced the financial security of the aged. Against this backdrop, the So-
cial Security Act was created over 60 years ago.
In June of 1934, President Franklin Roosevelt, in a message to the Congress,
announced his intention to provide a program for social security. Subsequently,
the president created, by executive order, the Committee on Economic Security.
The committee was instructed to study the problem of economic insecurity and
to make recommendations that would serve as the basis for legislation. Within six
months the committee made its report to the president. On January 17,1935, Pres-
ident Roosevelt introduced the report to both houses of Congress for simultane-
ous consideration. Each house eventually passed its own version, but in the end
the differences were resolved, and the Social Security Act was signed into law on
August 14, 1935. The new Act created a social insurance program designed to pay
retired workers age 65 or older a continuing income after retirement. More than
35 million Social Security cards were issued over the next two years.
The first Federal Insurance Contributions Act (FICA) taxes were collected
in January of 1937. Special trust funds were created for these dedicated rev-
enues. Benefits were then paid from the monies in the Social Security trust
funds. Over the years, more than $4.5 trillion has been paid into the trust funds,
and more than $4.1 trillion has been paid out in benefits (Social Security Ad-
ministration, n.d.). The remainder is currently on reserve in the trust funds, and
these funds will be used to pay future benefits. From 1937 until 1940, Social Se-
curity paid benefits in the form of a single, lump-sum payment. Payments of
monthly benefits began in January 1940, and such payments were authorized
not only for aged retired workers but for their aged wives or widows, children
under age 18, and surviving aged parents.
While the Social Security System was being established in 1935, parallel
efforts were also being undertaken to establish a national health insurance pro-
gram. A universal, government-sponsored U.S. health system has been under
discussion for many decades. The idea of government provision of health ser-
vices, often referred to at that time as "socialized medicine," was particularly
intriguing to proponents of the New Deal during the 1930s. Socialized medicine
was only one of several ideological proposals that emerged in the first two
Roosevelt administrations, but it was what organized medicine, primarily the
American Medical Association (AMA), targeted for attack during the next three
decades. It was ultimately defeated through AMA's intense lobbying. Socialized
medicine acquired a negative connotation because of the AMA campaign, and
the term was eventually replaced in the lexicon by "national health insurance"
(Cummings, 1979). The initiative resurfaced under the Truman administration,
but it did not really reemerge until the Great Society years of the Kennedy and
Johnson administrations, when Medicare and Medicaid were established.
Clinical Geropsychology and U.S. Federal Policy 21
After 20 years, the concept behind basic Social Security began to change,
and the idea of assuring economic security for disabled (younger) workers at-
tracted greater attention. The Social Security Amendments of 1954 initiated a
disability insurance program which provided Americans with additional cov-
erage against economic insecurity. At first, federal law merely allowed a dis-
ability "freeze" of a worker's Social Security record during the years when he
or she was unable to work. Although this measure offered no cash benefits, it
did prevent such periods of disability from reducing or wiping out retirement
and survivor benefits. The 1956 Social Security amendments provided bene-
fits to disabled workers aged 50 to 65 and disabled adult children. Over the
next 2 years, Congress broadened the scope of the program, permitting dis-
abled workers under age 50 and their dependents to qualify for benefits. By
1960,559,000 people were receiving disability benefits, with the average ben-
efit amount being approximately $80 per month. The number of people re-
ceiving disability benefits more than doubled from 1961 to 1969, increasing
from 742,000 to 1.7 million.
The decade ofthe 1960s brought major changes to the Social Security pro-
gram. Under the Amendments of 1961, the age at which men were first eligible
for old-age retirement benefits was lowered to 62, with benefits actuarially re-
duced (women previously were given this option starting in 1956). The most
significant change involved the signing ofthe Medicare bill on July 30,1965, by
President Lyndon Johnson. With the signing of this bill, SSA became responsi-
ble for administering a new health insurance program that extended health cov-
erage to almost all Americans aged 65 or older.
Medicare and Medicaid were enacted into public law in 1965, and nearly
20 million beneficiaries enrolled in Medicare in the first three years of the pro-
gram. In fiscal year 1996, Medicare covered approximately 37.5 million aged
and disabled persons (O'Sullivan & Price, 1996), and Medicaid had about 38.4
million recipients (Ford, 1996).
Medicare is a nationwide health insurance program of an entitlement na-
ture in which the primary beneficiaries are those eligible for Social Security dis-
ability benefits, various railroad retirees, and, most important. nearly every
senior citizen 65 years or older. Benefits under the program are uniform across
the nation, and one's eligibility does not depend upon income or financial as-
sets. Medicare is 100% federally financed.
Medicaid, on the other hand, is a medical assistance program (rather than
health insurance program) targeted for certain needy and low-income persons.
It is a state-operated and state- administered program, and each state has the
authority to create its own range of programmatic benefits within broad federal
guidelines. Medicaid is funded at various ratios, which can vary depending upon
a number of factors. The federal government will generally pay 50% of the med-
ical assistance costs incurred by a state. Physicians' services are a mandated bene-
fit, but mental health services are generally optional or supplemental benefits.
Accordingly, the actual provisions of the mental health components differ drasti-
cally from state to state depending upon local priorities, which can change at any
given time (DeLeon & VandenBos, 1980, pp. 258-59).
The initial Medicare mental health benefit package was considerably less
comprehensive than that for physical/organic illnesses. For example, inpatient
22 Gary R. VandenBos and Patrick H. Deleon
care in psychiatric hospitals was limited to less than 200 days over a person's en-
tire life, in sharp contrast to inpatient services for nonpsychiatric care. Further,
when an individual had a physical illness, he or she was required to pay only
20% copayment of the cost of outpatient care. Yet, if the diagnosis was mental
illness, the patient had a 50% copayment. with a $250 overall annual limit or
"cap" on reimbursement. No such comparable overall limit on outpatient phys-
ical health care services existed; instead a "usual and customary" fee schedule
was utilized. Psychologists were not expressly included as eligible providers un-
der Medicare; this exclusion set the stage for what would become a 25-year leg-
islative struggle for the direct recognition of psychologists under Medicare.
Of considerable historical significance to psychology is the fact that the
Senate report accompanying the original bill (the Social Security Amendments
of 1965, Public Law 89-97) set the tone of the orientation of Medicare as to the
role of physician-provided care when it expressly stated that "the committee's
bill provides that the physician is to be the key figure in determining utiliza-
tion of health services" (U.S. Senate, Committee on Finance, 1965. p. 46). In re-
sponse to subsequent efforts by various nonphysician health care providers to
broaden the basic orientation of the programs, Congress directed the Depart-
ment of Health, Education, and Welfare to conduct a formal study of the pos-
sibility of expanding the availability of various types of health services (Public
Law 90-248). In December 1968 the department submitted its Independent
Practitioners Study (Cohen, 1968) to Congress. While the report specifically
stated that the services of clinical psychologists should be reimbursed, it rec-
ommended that such services be reimbursed only when they are provided in
an organized setting and when there had been initial physician referral. Fur-
ther, the report recommended that a physician should establish a plan for the
patient's total care and also retain overall responsibility for patient manage-
ment (DeLeon, VandenBos, & Kraut, 1986). Thus, efforts had to be made to con-
tinue to develop mechanisms for elderly patients to have easier and direct
access to psychological services. Based on a 1972 amendment (Public Law 92-
603) the Colorado Medicare Study (Bent, Willens, & Lassen, 1983; McCall &
Rice, 1983) was conducted to test two alterations in the Medicare program,
namely, a larger proportion of allowable charges for outpatient mental health
services, and direct Medicare reimbursement to psychologists for providing
mental health services.
In the 1970s, SSA became responsible for a new disabilities-related pro-
gram, Supplemental Security Income (SSI). In the original 1935 Social Security
Act, programs were introduced for needy aged and blind individuals and, in
1950, needy disabled individuals were added. These three programs were
known as the "adult categories," and they were administered by state and local
governments with partial federal funding. Over the years, the state programs
became more complex and inconsistent, with many administrative agencies in-
volved, and payments varying more than 300% from state to state.
In 1969, President Nixon identified a need to reform these and related wel-
fare programs. In 1971, Secretary of Health, Education and Welfare Elliott
Richardson proposed that SSA assume responsibility for the adult categories. In
the Social Security Amendments of 1972, Congress federalized the adult cate-
gories by creating the SSI program and assigning responsibility for it to SSA.
More than 3 million people were transferred from state welfare programs to SSI.
Some feared that redirecting a significant proportion of effort away from a focus
on income security and health care access needs of the elderly would cause ad-
ministrative inefficiencies and otherwise be detrimental to the integrity of the
basic purpose of Social Security. The 1980 Social Security Amendments re-
quired SSA to conduct periodic reviews of current disability beneficiaries to
certify their continuing eligibility. By 1983, the reviews had been halted, and in
1984, Congress passed the Disability Benefits Reform Act modifying several as-
pects of the disability program, with a goal of reducing paperwork.
In the early 1980s the Social Security program faced a serious long-term fi-
nancing crisis. President Reagan appointed a blue-ribbon panel, known as the
Greenspan Commission, to study the financing issues and make recommenda-
tions for legislative changes. The final bill, signed into law in 1983, made nu-
merous changes in the Social Security and Medicare programs, including the
taxation of Social Security benefits, the first coverage of federal employees un-
der Social Security, and an increase in the retirement age in the next century.
Changes also continued to be made in the 1980s in terms of mental health
care. In 1980, psychological services and psychotherapy were expressly enu-
merated under several Medicare provisions (Public Law 96-499) authorizing
payment for rehabilitation services. In 1984, the first significant Medicare suc-
cess directly benefitting psychologists was the inclusion of language in the
Deficit Reduction Act of 1984 (Public Law 98-369) that authorized coverage for
psychologists as autonomous providers under the risk-sharing health main-
tenance organization (HMO) provisions of the Act. Public Law 98-369 also
allowed nonphysicians to head a Medicaid clinic. The Mental Health Organiza-
tional Amendments of 1986 (Public Law 99-660) explicitly listed psychologists
among the authorized HMO professions, whereas prior to this modification,
psychologists' services were actually recognized only under the broad heading
of "other health care providers."
In 1989, during the 101st Congress, professional psychologists finally ob-
tained direct and autonomous recognition under Medicare, as a provision of the
Omnibus Budget Reconciliation Act of 1989 (Public Law 101-239) (VandenBos,
Cummings, & DeLeon, 1992). On November 22,1989, Congress passed a large
package of bills, an omnibus budget reconciliation act, that included, among
others, direct reimbursement of psychologists for services provided to the el-
derly and the disabled under Medicare; on December 19, 1989, President Bush
signed the bill into law, effective on July 1, 1990. This landmark legislation
marked the end of the exclusion of psychologists as reimbursable providers of
services within the Medicare program, the only federal program that had ex-
cluded psychologists (Buie, 1990; Youngstrom, 1990). This legislation allowed
elderly patients access to the services of psychologists. In addition, the new
law removed many of the limits and arbitrarily low reimbursement ceilings
from both inpatient and outpatient mental health care, although mental health
services were still eligible for only 50% reimbursement (in contrast to 80% re-
imbursement for physical health services).
Throughout the 1980s and 1990s, there was growing bipartisan support for
removing SSA from under its departmental umbrella and establishing it as an
independent agency. Finally, in 1994 the Social Security Independence and
Program Improvements Act of 1994 (Public Law 103-296) was passed unani-
mously by Congress and, in a ceremony in the Rose Garden of the White House,
President Clinton signed the act into law on August 15,1994.
From its modest beginnings, Social Security has grown to become an es-
sential facet of modern life, and one of particular importance to the economic
security and health care of older Americans. One in seven Americans receives
a Social Security benefit, and more than 90% of all workers are in jobs covered
by Social Security. From 1940, when slightly more than 222,000 people re-
ceived monthly Social Security benefits, until today, when more than 42 mil-
lion people receive such benefits, Social Security has grown steadily. Thus, the
basic Social Security System (that is, the retirement pension portion) has been
in place for over 60 years and provides a base of financial income for almost
everyone over 65. This program has been successful in minimizing the number
of American elderly living in abject poverty. Although other retirement funds
are necessary for most elderly Americans to maintain the lifestyle of their adult
years, Social Security, when combined with other benefit programs and social
services, provides most elderly Americans with the means to meet their basic
needs with some degree of flexibility. In a parallel manner, Medicare provides
aged Americans with a guaranteed basic level of health care, although mental
health care still has somewhat inferior reimbursement provisions in compari-
son to physical health care.
CONTINIDNG POLICY AND

CLINICAL ISSUES
The sad fact is that the elderly are underserved by all current mental health
service delivery systems and all current health care funding mechanisms. The
mental health needs of the elderly simply are not being adequately met. In the
mid-1980s, there were approximately 26 million individuals aged 65 or older,
representing about 12% of the total U.S. population. Rough estimates suggested
that between 2.5 and 7.5 million individuals out ofthis elderly population had
emotional and behavioral problems that were serious enough to warrant pro-
fessional intervention, with federal estimates suggesting a target number of 5
million individuals.
Several factors seem to contribute to the underutilization of mental health
services among the elderly. It has been fashionable to talk about the anti-mental
health bias within the current elderly population. There is no question that to-
day's elderly are less psychologically sophisticated and less psychologically
oriented than younger age groups. Public information campaigns about the na-
ture of psychological and memory problems, and psychological and behavioral
interventions with them, would be useful activities for government, associa-
tions, and individual psychologists. However, the level of knowledge about
psychological issues and psychotherapeutic interventions is likely to increase
as a more highly educated and psychologically oriented middle-aged cohort en-
ters their retirement years.
Other reasons for the low utilization of mental health services by the elderly
include misinformation about the nature and value of psychological care; lack of
knowledge about the availability of services; inaccessibility due to a general lack

of integrated support services (e.g., outreach, home visits, and transportation);
the intimidating regulations and paperwork required for mental health insur-
ance benefits; bias among mental health providers regarding the elderly; and fi-
nancial, language, and cultural barriers in the case of elderly minorities.
Until very recently, major biases in the funding mechanisms have made it
difficult for the elderly to seek psychological help. These include the artificial cap
on mental health services funding under Medicare and the ineligibility for reim-
bursement of psychologists and other non physician mental health professionals
by this program. As noted. these regulations were amended in 1990, so the pat-
tern of underutilization by the elderly will soon change. Thus, it is critical for
clinical geropsychology to expand and evolve rapidly so that more professional
psychologists are prepared for and experienced in working with older patients.
Psychological and behavioral issues related to the elderly have been rela-
tively neglected in psychology training programs for a long time (Storandt,
1982). Surveys in the mid-1970s revealed that as few as 100 psychologists had
specialized training concentrated on serving older populations and that only a
handful of programs had some type of clinical track that might be referred to as
clinical geropsychology. Later, geropsychology training conferences (Knight,
Teri, Wohlford, & Santos, 1995) found improvements in the availability of pre-
doctoral course work and practicum, although such availability is still far from
widespread. Moreover, aging-related knowledge is often presented to students
across several courses, such as psychopathology, neuropsychology, health psy-
chology, psychopharmacology, and so forth. Without a core course that serves
as a coordinating point for such scholarly knowledge, it may be difficult to in-
tegrate all of the separate pieces with the normal developmental tasks and func-
tions of older adults. It may be necessary, in the short term, for the federal
government to target training support for clinical geropsychology, whether from
Social Security funds, General Medical Education (GME) support, or National
Institutes of Mental Health (NIMH) training grants. It will take active advocacy
efforts by psychologists for this to occur.
In many ways, clinical problems for which older individuals see psycholo-
gists are similar to those of other age groups in the general U.S. population. This
means that many skills learned and refined with other age groups can be trans-
ferred to clinical work with the elderly, once appropriate supplemental knowl-
edge is acquired. The elderly, as a group, are generally found to have slightly
fewer mental health problems of all types, with the exception of dementia. The
major mental health problems among the elderly include depression and other
mood disorders; dementia and severe cognitive impairment; suicide (particu-
larly among men over 75); alcohol abuse; polydrug use and misuse of prescrip-
tion medications; and chronic mental disability. Such problems frequently
involve difficult behavior, memory problems, and strained family and social
relations (VandenBos, 1993). Fortunately, new books and other resources are be-
coming available for use by practicing professionals, continuing education (eE)
trainers, and predoctoral education. Such resources include A Guide to Psy-
chotherapy and Aging: Effective Clinical Intervention in a Life-Stage Context
(Zarit & Knight, 1996) and Neuropsychological Assessment of Dementia and
Depression in Older Adults: A Clinical Guide (Storandt & VandenBos, 1994).
The financing of long-term nursing home care is a continuing unresolved

policy issue relevant to older populations. Older Americans are generally living
on fixed incomes with little potential for increases from year to year. The hall-
mark of federal initiatives related to the elderly over the last 60 years has been
the protection from unexpected and sudden catastrophic financial ruin. Basic
Social Security provided a guaranteed income in old age. Medicare and Medic-
aid provided protection from catastrophic health care costs. Perhaps the last cat-
astrophic financial risk for the elderly yet to be addressed relates to long-term
care. Twenty-four-hour day care in a residential facility is expensive and can
wipe out an individual's lifetime savings in a short period of time. Although, at
any given moment, only 5% of persons over 65 reside in a nursing home, the
chance that people who survive to age 65 will enter a nursing home for some pe-
riod of time before their death is better than one in four (Berkman & Kane, 1993).
However, for every nursing home resident, two equally impaired individu-
als are living in a community. Thus, availability of community-based home
health care is vital. Impaired community-based elders sometimes struggle along
caring for themselves under great hardship, and in other cases they survive
with occasional help from family members or nearby neighbors. Availability
and quality of home care services vary greatly from community to community,
and the funding is often precarious. Despite the fact that home care services can
be highly cost effective by both preventing institutionalization and encouraging
self-reliance and independent functioning, such services often lack a firm leg-
islative base. It is vital that, at both federal and state levels, legislative initiatives
for provision of long-term care or preventive home care be supported by clini-
cal geropsychologists.
Nursing homes and home care programs also offer the potential for clini-
cal geropsychologists to have an important clinical impact and to gain em-
ployment. Clinically significant depression and anxiety are generally apparent
in large percentages of the resident population of nursing homes. Clinical gero-
psychologists are needed in such settings for screening, short-term clinical
interventions, and family work, and clinical opportunities exist for geropsy-
chologists in home health care programs. Many individuals recuperating
at home from physical problems and those coping with long-term chronic
conditions often have elevated levels of depressive symptomatology. Social
support, presence versus absence of psychopathology, and access to psycho-
educational information are correlated with speed of recovery and return to
self-care functional levels among those receiving home health care services.
Clinical geropsychologists can aid in such programming as clinical super-
visors, program managers, and direct services providers to more severely
impaired individuals. However, advocacy is needed to assure that such con-
ceptualizations (and clinical positions) are built into the legislation authoriz-
ing such service programs.
One message that is important for geropsychologists to introduce into leg-
islative and policy discussions is the concept of individual differences. Far too
often legislators working on one issue or another conceptualize older individu-
als in some overly simplified manner. It might be that the image of the nursing
home resident momentarily stands as the image for all older adults, when at an-
other moment the image of a frail 80-year-old man timidly driving a large car
through busy traffic may stand as the image for all older drivers. Geropsycholo-
gists, likewise, need to remind legislators that there may be vast differences in
physical health and psychological functioning between two 74-year-old indi-
viduals. Just as individual differences exist and are important among children,
teenagers, and middle-aged adults, such differences exist in elderly populations,
but may be momentarily forgotten as policy officials address a particular social
issue related to a particular subset of the elderly. Legislative solutions to partic-
ular social problems must be crafted and applied with an awareness of such in-
dividual differences so as not to unintentionally hamper the functioning of other
older individuals with different abilities and functional capacities.
SUMMARY
American society is aging. Older individuals will increasingly present
clinical challenges to professional psychologists. Our training systems must
continue to evolve so that all practitioners are appropriately trained and expe-
rienced to serve the psychological needs of older individuals. And psychology
must also work to ensure that appropriate, fair, and equitable funding mecha-
nisms are in place, so as to permit older individuals direct access to needed
psychological care.
REFERENCES
Bent, R. J., Willens, J. G., & Lassen, C. L. (1983). The Colorado Clinical Psychology/Expanded Men-
tal Health Benefits Experiment: An introductory commentary. American Psychologist, 38,
1274-1278.
Berkman, B., & Kane, R. A. (1993). Social work services for older people in acute or long-term care.
In F. Lieberman & M. F. Collen (Eds.), Aging in good health: A quality lifestyle for the later
years (pp. 279-294). New York: Plenum.
Buie, J. (1990, January). President signs Medicare bill. Victory caps uphill trek. APA Monitor, 21, pp.
1,17-19.
Bureau of the Census, U.S. Department of Commerce. (1980, December). Social indicators III. Se-
lected data on social conditions and trends in the United States. Washington, DC: Federal Sta-
tistical System.
Cohen, W. J. (1968). Independent practitioners under Medicare: A report to the Congress. Washing-
ton, DC: Department of Health, Education, and Welfare.
Cummings, N. A. (1979). Mental health and national health insurance: A case history of the strug-
gle for professional autonomy. In C. A. Kiesler, N. A. Cummings, & G. R. VandenBos (Eds.),
Psychology and national health insurance (pp. 5-16). Washington, DC: American Psycholog-
ical Association.
Cummings, N. A., & VandenBos, G. R. (1983). Relations with other professions. In C. E. Walker (Ed.),
Handbook of clinical psychology (pp. 1301-1327). Homewood, IL: Dow-Jones.
DeLeon, P. H., & VandenBos, G. R. (1980). Psychotherapy reimbursement in federal programs: Po-
litical factors. In G. R. VandenBos (Ed.), Psychotherapy: Practice, research, policy (pp.
247-284). Sage studies in community mental health #1. Beverly Hills, CA: Sage.
DeLeon, P. H., VandenBos, G. R., & Kraut, A. G. (1986). Federal recognition of psychology as a pro-
fession. In H. Dorken & Associates (Eds.), Professional psychology in transition: Meeting to-
day's challenges (pp. 99-117). San Francisco, CA: Jossey-Bass.
Ford, M. (1996, March 26). Medicaid reform. CRS issue brief. Washington, DC: Congressional Re-
search Service, Education and Public Welfare Division, Library of Congress.
Knight. B. G., Teri, L., Wohlford, P., & Santos. J. (Eds.). (1995). Mental health services for older
adults: Implications for training and practice in geropsychology. Washington, DC: American
McCall, N., & Rice, T. (1983). A summary of the Colorado Clinical Psychology/Expanded Mental
Health Benefits Experiment. American Psychologist, 38, 1279-1291.
Neugarten, B. 1., & Neugarten, D. A. (1989). Policy issues in an aging society. In M. Storandt &
G. R VandenBos (Eds.), The adult years: Continuity and change (pp. 147-167). Washington,
DC: American Psychological Association.
O'Sullivan, J., & Price, R (1996, May 31). Medicare. CRS issue brief Washington, DC: Congressional
Research Service, Education and Public Welfare Division, Library of Congress.
Social Security Administration. (n.d.). Social security-A brief history. Retrieved from World Wide
Web: httpllwww.ssa.gov/history/history.html.
Storandt, M. (1982). Where have we been? Where are we going? In J. F. Santos & G. R VandenBos
(Eds.), Psychology and the older adult: Challenges for training in the 1980s (pp. 11-17). Wash-
ington, DC: American Psychological Association.
Storandt, M., & VandenBos, G. R (Eds.). (1994). Neuropsychological assessment of dementia and
depression in older adults: A clinician's guide. Washington, DC: American Psychological
Association.
U.S. Senate, Committee on Finance. (1965). Social Security Amendments of 1965 (U.S. Senate re-
port No. 389-404, Part 1, to accompany H.R 6675). Washington, DC: U.S. Government Print-
ing Office.
VandenBos, G. R (1993). Psychology and the mental health needs ofthe elderly. In F. Lieberman &
M. F. Collen (Eds.), Aging in good health: A quality lifestyle for the later years (pp. 189-202).
New York: Plenum.
VandenBos, G. R, Cummings, N. A., & DeLeon, P. H. (1992). A century of psychotherapy: Economic
and environmental influences. In D. K. Freedheim (Ed.), History of psychotherapy: A century
of change (pp. 65-102). Washington, DC: American Psychological Association.
Youngstrom, N. (1990, July). Register with carrier for Medicare payment. APA Monitor, 21, p. 23.
Zarit, S. H., & Knight, B. G. (Eds.). (1996). A guide to psychotherapy and aging: Effective clinical
interventions in a life-stage context. Washington, DC: American Psychological Association.
CHAPTER 3
Psychodynamic Issues
HOWARD D. LERNER
INTRODUCTION
Psychoanalytic theory does not offer a single, coherent account of the aging
process across the life cycle. First, psychoanalysis does not represent one uni-
fied, tightly knit theory. As explored in the first section of this chapter, psycho-
analysis can be represented by four internally consistent theoretical models
that, to a large extent, intersect and overlap but that cannot be unified into a sin-
gle theory. Each model offers its own perspective on geropsychology. Second,
from the perspective of psychoanalytic theorists and clinicians, issues involv-
ing geropsychology are far too complex and multi determined to elaborate in
terms of a single thread or dimension. In this chapter, therefore, aging will be
examined in terms of eight "dimensions of development." These dimensions, as
will be articulated, interdigitate with one another in complex ways. However,
for heuristic reasons, each will be considered separately in order to offer some
idea of the rich tapestry that comprises geriatric psychology from the perspec-
tive of psychoanalytic theory.
Psychoanalysis has traditionally focused little attention on aging. Its focus
has been on internal, intrapsychic development during the first five or so years
of life and the impact that this early development exerts on all ensuing devel-
opment. In recent years, however, psychoanalytic theorists have paid increas-
ing attention to the vicissitudes of development at all stages through the life
cycle and have considered the ongoing influence that real-life experiences
such as trauma, aging, and close relationships exert on the individual's inner
world. The aim of this chapter is to integrate the central emphasis within psy-
choanalysis on internal experience with its increased attention to the for-
mative impact of ongoing processes of maturation and real-life experience. In
the first section of this chapter, the four dominant conceptual paradigms of
psychoanalysis will be examined as a general introduction to contemporary
HOWARD D. LERNER • Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
48104.
29
30 Howard D. Lerner
psychoanalytic thought and to establish a conceptual framework for the dis-

cussion that follows. Specific issues in aging will then be examined to demon-
strate how psychoanalysis has come to incorporate the role of ongoing life
experience into a predominantly internal, intrapsychic framework. In the third
section, eight dimensions of development will be examined in order to shed
light on the question of what, in fact, develops in aging and what the nature of
this development is. In the final section, to add specificity to the discussion,
the issue of aging and the mourning process will be examined.
PSYCHOANALYTIC MODELS
In formulating a psychoanalytic approach to geropsychology, it is impor-

tant to recognize that psychoanalysis is not one closed, totally coherent theory
of personality. Rather, it consists of a loose-fitting composite of four comple-
mentary, internally consistent models. Each model furnishes formulations for
observing and understanding crucial dimensions of personality development.
Through the course of Freud's writings, he developed a wide range of for-
mulations concerning psychological functioning and accordingly created various
conceptualizations of the mind and how it works. He changed from one theory to
another theory whenever prior concepts failed to explain newly observed phe-
nomena. However, the transition from one set of formulations to another did not
indicate that one superseded the other. That is, Freud did not intend to dispense
with older concepts as he proposed newer ones. He assumed that a given set of
clinical phenomena might be understood most clearly by using one frame of ref-
erence, whereas another set of data required a different set of concepts to explain
the data. The principle of several concurrent and valid avenues for organizing the
data of observation has been termed theoretical complementarity (Gedo & Gold-
berg, 1973). This is consistent with Waelder's (1930) notion of the principle of
multiple functioning of the psychic apparatus that recognizes that the "final
pathway" in behavior is a compromise that serves many masters or psychic agen-
cies. No single motive or significant factor can ever be isolated.
Psychology of the Self
Heinz Kohut (1971, 1977), in a series of influential publications, laid the

theoretical foundation for a systematic psychoanalytic psychology of the self.
Self psychology may be characterized by its emphasis on the vicissitudes of the
structure of the self, the associated subjective, conscious, preconscious, and un-
conscious experience of selfhood, and the self in relation to sustaining "self-
objects." The "selfobject" is one's subjective experience of another person who
provides a sustaining function to the self within a relationship, evoking and
maintaining the self and the experience of selfhood by his or her presence or ac-
tivity. Kohut (1977) suggests that individuals need significant others who can
assume selfobject functions throughout the life cycle. Self psychology recog-
nizes as the most significant need of the individual to organize his or her inter-
Psychodynamic Issues 31
nal world into a cohesive configuration, the self, and to establish self-sustaining
relationships between this self and its surroundings: that is, relationships that
evoke, maintain, and strengthen one's sense of coherence, vigor, and balanced
harmony among the constituents of the self. In psychoanalytic treatment, from
this perspective, empathy is considered to be the cardinal means of data col-
lection and the primary therapeutic instrument.
Utilizing a self psychology approach, Muslin (1992) has offered the follow-
ing definition of the "elderly self":
The elderly self is the self of aging people that has become altered in all or many of its
structures and functions in reaction to a constellation of societal and biological influ-
ences that reflect a particular society's views of an aging person, as well as the indi-
vidual's biological givens. An "elderly self" is a self that has passed through specific
alterations in its self structures that have evolved in reaction to the specific internal
and external milieus. A cohesive elderly self is one in which the self-alterations have
resulted in an adaptive self without the symptoms and signs of excessive reactions to
the external world in the form of loss of worth or self-fragmentation and its vicissi-
tudes as evidenced in neurosis or psychosis. (p. 5)
Object Relations Theory
A second major advance within psychoanalytic theory is modern object re-

lations theory. Object relations theory, or "object-relational thinking" (Guntrip,
1974), does not constitute a singular organized set of concepts, principles, for-
mulations, or a systematized theory. Rather, it represents a broad spectrum of
thought that historically and collectively has taken the form of a significant
movement within psychoanalysis. Within object relations theory, the concept of
object representation has served as a superordinate construct. Defined broadly,
object representation refers to the conscious and unconscious mental schemata,
including cognitive, affective, and experiential dimensions of others, termed
"objects," encountered in reality (Blatt, 1974). From a developmental perspec-
tive, beginning within an interpersonal matrix as vague and variable sensori-
motor experience of pleasure and unpleasure, these schemata develop into
increasingly differentiated, consistent, and relatively realistic representations of
the self and the world of others. Developmentally, earlier forms of representa-
tions are based more on action sequences associated with gratification of basic
needs; intermediate forms are based on specific perceptual features; and higher
forms are thought to be more symbolic and conceptual. Whereas these schemata
evolve from and are intertwined with the developmental internalization of
object relations and ego functions, the developing representations provide a
new organization or template throughout the life span for experiencing ongoing
interpersonal relationships internally. From this perspective, psychoanalytic
treatment attempts to help elucidate, articulate, and, it is hoped, modify one's
internal representation of one's self and one's self in relationship to other peo-
ple. Recently, some proponents of both self psychology and object relations the-
ory have defined themselves as "relational theorists," and have moved from
what they term a "one person psychology," which they link to classical Freud-
ian thinking, to what they term a "two person psychology."
32 Howard D. Lerner
Modern Structural Theory
A third major dimension in psychoanalysis has been modern structuraJ the-

DIy. Taking as its point of departure S. Freud's (1923/1957) tripartite model ofid,
ego, and superego, and dispensing with older concepts of psychic energy such as
libido, modern structural theory, despite challenges from other perspectives, re-
mains the "mainstream hypothesis of modern psychoanalysis" (Boesky, 1989).
Modern structural theory takes as its fundamental assumption the ubiquitous
nature of internal conflict throughout the life cycle and the view that this conflict
can be conceptualized broadly through the interaction of the id, ego, and super-
ego. Charles Brenner has been one of the most articulate spokesmen for this point
of view. According to Brenner, internal conflict is at the heart of psychoanalytic
theory and treatment, the components and interactions of which result in "com-
promise formations." All thoughts, actions, plans, fantasies, and symptoms are
thought of as compromise formations, which are understood to be multideter-
mined by the components of conflict. All compromise formations represent a
combination of a drive derivative (a specific personal and unique wish of an in-
dividual, originating in childhood, for gratification); unpleasure in the form of
anxiety or depressive affect and their ideational contents of either object loss, loss
of other, or bodily damage associated with the drive derivative; defense that func-
tions to minimize unpleasure; and various manifestations of superego or moral
functioning such as guilt, self punishment, remorse, and atonement.
According to Brenner (1986), compromise formations are the observational
database for the study of all psychic functioning; that is, they are the data of ob-
servation when one applies the psychoanalytic method to observe all psycho-
logical phenomena.
To say everything is a compromise formation. means everything. Not just symptoms.
not just neurotic character traits. not just the slips and errors of daily living. but every-
thing, the normal as well as the pathological. Just as nothing is ever just defense or
only wish-fulfillment. so nothing is ever only "realistic" as opposed to "neurotic."
One of the principal contributions of psychoanalysis to human psychology is pre-
cisely this. The various components of conflict over wishes of childhood origin play
as important a part in normal psychic functioning as they do in pathological psychic
functioning. (p. 41)
From the perspective of modern structural theory, important questions

asked for understanding all psychological phenomena, including those of ag-
ing, are, What wishes of childhood are being gratified? What unpleasure or pain
(anxiety and depressive affect) are they arousing? What are the defensive and
superego aspects? According to Brenner, the answers to these questions provide
a distinctive psychoanalytic understanding of all psychological phenomena
and in the treatment situation guide the timing and nature of interactions.
Developmental Theory
A fourth and increasingly popular major model in psychoanalysis is a dy-

namically based, developmental theory. Several contemporary clinicians, the-
orists, and researchers have concluded independently that developmentally
salient aspects of psychological structure and functioning are initiated in and

stem from the early mother-child relationship. The developmental perspective
provides an assimilative and unifying focus within which multiple approaches
can be organized to understand the vicissitudes of aging. The developmental
perspective is rooted deeply in the psychoanalytic tradition and embraces all
aspects of psychological functioning, especially the relationship between past
experience and present functioning (temporal progression), between early
trauma and present symptoms (phase-specific deficits), and between historical
actualities and psychic realities. In addition, a developmental focus provides a
framework for discerning the relative ideological weight of constitutional and
experiential factors throughout the life cycle.
The developmental approach within psychoanalysis, especially as it has
been built upon the systematic, naturalistic, and longitudinal study of infants
and children, provides a methodological link between psychoanalysis and the
social sciences and a bridge between clinical and research approaches to the in-
dividual. Mahler and her colleagues (Mahler, Pine, & Bergman, 1975) have care-
fully observed children and their caregivers and have described the steps in
what they term the separation-individuation process. Beginning with the earli-
est signs of the infant's differentiation or "hatching" from a symbiotic fusion
with the mother, the infant proceeds through the period of his or her absorption
in his or her own autonomous functioning to the near exclusion of the mother
(practicing subphase), then through the all-important period ofrapprochement
in which the child, precisely because of a more clearly perceived state of sepa-
rateness from mother, is prompted to redirect attention back to the mother,
often in provocative ways, and finally to a feeling of a primitive sense of indi-
vidual identity and of object constancy. Several authors, including Behrends
and Blatt (1985), have conceptualized the major task throughout the course of
the life cycle as a continuation of this separation-individuation process, which
is accomplished through progressive internalization of need gratifying aspects
of relationships with significant others.
In his seminal work based on empirical data, Erik Erikson (1976) described
stages in ego or self development at eight different stages of life. Each stage was
thought to present its own psychosocial crisis. If the crisis is satisfactorily
resolved, a positive quality is added to development. If it is unsatisfactorily
resolved, a negative factor is added. Erikson's eight stages of the life cycle are as
follows: trust versus mistrust which leads to hope; autonomy versus shame and
doubt which leads to will; initiative versus guilt which leads to a sense of pur-
pose; industry versus inferiority which gives rise to a sense of competence; the
adolescent crisis of identity versus identity confusion; in young adulthood, the
conflict of intimacy versus isolation; in the mature years, generativity versus
self-absorption; and finally, the task of old age, which is integrity versus despair
and disgust, in which a favorable outcome gives rise to wisdom.
The studies of Mahler and her colleagues, and Erikson combine many of the
empirical values extant in the social sciences with the intensive, clinical study
of single subjects favored by psychoanalysis. The developmental perspective
and associated methodologies offer a corrective influence for both blind ad-
herence to theoretical constructs and equally blind reliance on group data
and inferential statistics. This approach thus offers a flexible balance between
34 Howard D. Lerner
idiographic and nomothetic methodologies, while providing a context from

which to distill theoretical formulations as they emerge from and are rooted in
human experience throughout the life cycle.
ADULT DEVELOPMENT:
GENERAL CONSIDERATIONS
Traditionally, psychoanalysis has viewed adulthood as the endpoint of de-

velopment. An epic of relative quietude and stability, adulthood has stood
within psychoanalysis as a monument to the formative developmental experi-
ences of the early years and to the resurgence of developmental processes cat-
alyzed at puberty that characterizes adolescence. In general, psychoanalysts
have conceptualized childhood in terms of its ongoing, age-specific develop-
mental tasks. In contrast, they have seen adulthood in terms of already accom-
plished developmental tasks.
From its inception, psychoanalysis has viewed early, infantile develop-
ment as decisive for all subsequent personality development. Emphasis was on
the past, in what was formative. Traditionally, psychoanalytic thinkers have
emphasized the repetitive nature of human behavior, stressing the individual's
drive to reenact early, formative, and unconscious experience, conflict, and fan-
tasy throughout life.
Although the formative impact of early development remains a cornerstone
of psychoanalytic theory and treatment, psychoanalysts increasingly have moved
to explore the ways in which development proceeds across the life cycle. A de-
velopmental point of view implies an ongoing process, not only with a past, but
also with a present and future. From this vantage point, early phases of life, not
only early childhood, bring with them distinctive developmental challenges and
possibilities. Further, advances in psychological structure are seen as accruing
across all phases of the life cycle, including late adulthood, so that each develop-
mental experience is thought to incorporate all development that precedes it.
Erik Erikson was the first psychoanalyst to advance an integrated psy-
chosocial view of individual development through the course of the life cycle.
Erikson has had an enormous impact in various fields throughout the social sci-
ences and humanities. He has highlighted the interaction between the individ-
ual's internal psychological state and external social events. Central to the
Eriksonian perspective on development is the "epigenetic" principal, which as-
sumes that anything that grows has an internal "game plan." Each stage of life,
including those that comprise adulthood, brings with it new challenges that the
individual must master. According to this point of view, individuals who are
able to meet these tasks or challenges create the opportunity to face life with re-
newed energy, creativity, and adaptive capacities. Each of Erikson's previously
mentioned eight stages revolves around a crucial developmental task for the in-
dividual self in relation to the social world. According to Erikson, in the sixth,
or young adult stage (20s and 30s), the individual deals with issues of intimacy
versus self-absorption. Issues of intimacy, sexuality, and empathy in the context
of a cohesive sense of self in relationship with another person are salient. In the
seventh or mid-life period, the task or conflict is between generativity and stag-
nation. Here, generativity goes beyond the care of one's own children to guiding
or mentoring the next generation through teaching, creativity, and, most impor-
tantly, participation in society. In the eighth or last stage, the conflict is between
integrity and despair with integrity epitomizing an acceptance of one's life as it
has been lived and letting it go with equanimity.
Settlage and his colleagues (Settlage, Curtis, Lozoff, Silbershatz, & Sim-
burg, 1988) compare personality development in adulthood with the devel-
opmental processes of childhood and adolescence. Development, the authors
suggest, is a
process of growth, differentiation, and integration that progresses from lower and sim-
pler to higher and more complex forms of organization and functioning ... the func-
tions and structures resulting from development constitute additions to or advances in
the self-regulatory and adaptive capacities. (p. 35)
Psychoanalysts have traditionally conceptualized personality development

as occurring at the interface between the individual's internal biological matu-
ration and environmental forces that he or she faces. Specifically, personality
formation proceeds in the context of a predetermined unfolding of stages in
childhood and the biologically driven resurgence of strivings of puberty. Al-
though biological maturation contributes to psychological development in
adulthood and biological changes have a major impact on old age, the impact of
biological forces are less dramatic and clear-cut than in childhood; however,
easily discerned, predetermined, invariant stages of maturation characterize
psychological development in the adult years.
In light of these considerations, Settlage and colleagues (1988) suggest that
personality development in adulthood be conceptualized in terms of a develop-
mental process. Within this context, the stimulus for development is a disruption
in the individual's previously adequate self-regulatory and adaptive functions.
Such a disruption can come in the form of biological maturation or change, envi-
ronmental demand, a traumatic event such as loss, or a self-initiated pursuit of
better adaptation. Examples of events or experiences that disrupt adult psychic
equilibrium, particularly in the more advanced years, include loss of parents and
potentially of spouse, retirement, illnesses, and loss of functions due to aging.
In response to developmental challenges, the individual experiences a
conflict in which he or she must confront the need to adapt and attempt to ne-
gotiate the anxiety and conflict that any change entails. Resolution of develop-
mental conflict potentially leads to structural change in self-regulatory and
adaptive functioning. In turn this can lead to a change in the individual's self
and object representations, level of separation-individuation, sense of identity,
self-esteem, and compromise formations.
MULTIPLE DIMENSIONS OF DEVELOPMENT

IN OLD AGE: A LIFE CYCLE PERSPECTIVE
In constructing a psychoanalytic framework for development across the life

cycle, it is essential to clarify what, in fact, develops. Anna Freud (1965), in
her deceptively simple yet sophisticated way, offered a significant conceptual
36 Howard D. Lerner
framework in her discussion of "developmental lines." She described develop-

mental lines in terms of fundamental aspects of personality that unfold in a reg-
ular sequence in the context of child and adolescent maturation. She described,
as examples, one developmental line that leads from dependency to emotional
self-reliance and another that leads from irresponsibility to responsibility in
body management. Several authors have advanced perspectives on develop-
ment that allow us to expand on Anna Freud's valuable concept of develop-
mental lines; these perspectives are termed dimensions of development and
they are extended across the life cycle to old age. The model of dimensions of
development has been applied to adolescents (Lerner, 1987; Sugarman, Bloom-
Feshbach, & Bloom-Feshbach, 1980) and social development across the life cy-
cle (Lerner & Ehrlich, 1992).
As outlined by Lerner and Ehrlich (1992) the major task of adult develop-
ment is synthesis-specifically, the integration of the various dimensions of de-
velopment (psychosocial, cognitive, moral, etc.). The dimensions may integrate
and reintegrate, at higher or lower levels of synthesis, around nodal points or
tasks in development such as marriage, parenthood, retirement, and loss-what
Neugarten (1979) refers to as "the normal turning points, the punctuation marks
along the lifeline" (p. 889). In terms of old age, the dimensions of development
may also be thought to integrate and reintegrate either toward higher or lower
levels of adaptation around such crises as decline in bodily function, serious ill-
nesses, losses, and, ultimately confronting death.
The eight dimensions of development that are examined next entail salient
aspects of psychological development beginning in childhood that are trans-
formed over time and are shaped by both maturation and life experience. Al-
though actual development is multifaceted and exceedingly complex, these
dimensions of development will be considered separately for heuristic and con-
ceptual purposes.
As Neugarten (1979) reminds us, old age presents both old and new issues.
Some of these issues are connected to renunciation such as adapting to losses,
relinquishment of a position of authority, and questioning of one's former com-
petencies; the reconciliation with significant others of one's achievements and
failures; the resolution of grief over the death of important others and of one's
own approaching death; the maintenance of a sense of integrity in terms of what
one has been, rather than what one is, and the concern over legacy and how to
leave traces of oneself.
Old age is not what many imagine. It is, in fact, becoming a longer portion
of the life cycle. With improved health care, the fastest-growing segment of the
population is composed of persons 85 years old and older. Individuals over 65
are becoming an increasingly powerful force in society. A larger proportion of
individuals 65 and older vote than any other age group in the population. The
American Association of Retired Persons, with more than 32 million members,
is among the most powerful lobbying groups in Washington. There are many
myths about old age that conceal the triumphs of survivorship and the recog-
nition that one has weathered a wide range of experiences and therefore has a
certain "savoir faire" in ways in which younger people cannot know. These in-
clude knowledge and strength from having lived through physical and psycho-
logical pain that can give confidence that one can recover and deal also with the
contingencies that lie ahead (the sense that one is now the possessor and con-
servator of eternal truths, or what Erikson terms wisdom).
Psychosexual Development: Drives and Bodily Experience
There is general agreement among most psychoanalysts that many of the

major psychosexual passions and conflicts of the first five years of life are rekin-
dled and reworked not only during adolescence but also at other nodal points of
adulthood. The notion of psychosexual stages was S. Freud's (1905/1951) frame
of reference for conceptualizing development based on his examination of the
origin and dynamics of neurotic symptoms and character traits that he con-
nected to successive phases of the libidinal drives. He had observed that early
phases of what he termed "infantile sexuality" were organized around energic
investment of the oral, anal, and phallic erotogenic bodily zones, each achieving,
in turn, a relative dominance over the preceding phases. Bodily activities and
sensations connected with each zone are thought to be accompanied by phase-
related fantasies and conflicts with the parents or other important persons in the
child's environment. Despite the continuum in sensual experience (G. Klein,
1976) implied in Freud's theory of psychosexual development, few have traced
the developmental line of psychosexuality into adulthood.
Colarusso and Nemiroff (1981) observed that in American society there is a
tendency to associate increased age with a decrease in sexual interest and ac-
tivity. This myth of diminished sexuality with age is not biologically mandated.
Far-reaching and deep social and cultural changes have brought about a greater
flexibility in social norms regarding sex roles and increased external freedom,
despite the AIDS epidemic. For many, however, external freedom does not
bring about a corresponding internal freedom from conflict. For example, the
women's movement has brought new role conflict for women who simultane-
ously pursue occupational success and motherhood and for men who seek new
freedom and new combinations of roles as worker, parent, and homemaker. As
Neugarten (1979) observes, for women there is new freedom and increased
energy available when children leave home, and freedom from unwanted preg-
nancy and, for many, new pleasures in sexual activity that accompany meno-
pause. Nevertheless, for both sexes, there is an increased realization that, with
age, the body is increasingly less predictable than earlier and there is increased
attention to body monitoring. The psychological counterpart of the inevitable
aging of the body is changes in the experience of time. Middle age is thought to
bring with it a change in time perspective, in that time becomes restructured in
terms of time left to live rather than time since birth.
Sexual behavior changes with aging (Harman, 1978; Martin, 1977). The
most significant factors in determining the level of sexual activity with increased
age appear to be general health and survival of the spouse. Colarusso and Ne-
miroff (1981), based on their review of the biological literature on aging, con-
clude that some degree of declining sexual function and interest appears to be an
inevitable consequence of aging, but health, social, and cultural factors rather
than physiological change per se seem to be responsible for most of the sexual
changes seen with aging. These authors note that prevalent attitudes about brain
38 Howard D. Lerner
functioning in late adulthood are just as skewed as those about sexual function-
ing. Mental functioning need not necessarily decline with age because of in-
evitable degenerative changes in the brain. Health, social factors, interpersonal
relationships, and environmental stimulation, rather than a decline in brain
functioning and the central nervous system, appear to be important determi-
nants of the course of psychological development in middle and late adulthood.
Attitudes toward the body change through the life span. During adolescence
and early adulthood there is a casual acceptance of the body with concerns re-
volving around invincibility versus vulnerability as well as the development of
physical abilities and care of the body. Through the 30s and 40s there is a grow-
ing awareness of physical limitations, often signaled by baldness, gray hair,
wrinkles, and changes in vision. These changes are reflected in fantasies having
to do with the body of youth, a mourning process, and the emergence of a new
body image, one that increasingly approximates reality with an acceptance of
physical limitations an:d an enjoyment of the body in new ways. With advanced
age, continued care or neglect of the body becomes an increasingly important
psychological issue. With this come increased efforts to compensate for dimin-
ished physical energy by altering schedules, diets, and sleep patterns. These
changes are also accompanied by increased fantasies of death, heart attacks, and,
for many women, widowhood. With increased time, the psychological focus be-
comes one of remaining active despite frequent physical infirmity and with it
the acceptance of permanent, irreversible physical impairment.
The Psychosocial Dimension: Striving for Ego Identity
As has been noted, most classical psychoanalytic thinkers beginning with

Freud have conceptualized development from an intrapsychic perspective.
Erikson, however, in a series of influential papers and books, has stressed the
importance of the broader social context. It is specifically within the context of
the task of integrating psychosexual and bodily changes that Erikson notes that
the adolescent is confronted with the difficult task of assessing society, assimi-
lating those values that appear sensible, and finding a place within society. To
do so, according to Erikson, is to development a sense of identity, a sense of
who one is as a unique individual across different situations and through his-
torical time, a sense of self-sameness.
Formation of identity, however, does not end with adolescence. The adult
phases of the life span require a continuing although less rapid and dramatic
evolution, refinement, and maturation of identity for the maintenance of opti-
mal adaptation and functioning. Michels (1980) has outlined four major themes
of adult develop that can be considered in terms of their impact on ego identity:
work, sex, parenthood, and aging.
One major task of adulthood involves development and integration of a
work identity. During adolescence and young adulthood, the ability to make
choices, to identify and develop work skills, to maintain a capacity for sus-
tained and committed work and derive pleasure from it, as well as the experi-
ence of success and failure in the workplace are key determinants of an adult
work identity. The role of a mentor relationship is often instrumental during
this phase as well as during the 30s, in which there is a solidification of a work
identity, the continued development of skills, increased attention to levels of
achievement in terms of economic and social status, and increased internal and
external pressures involving balancing of work and family life.
Through the 40s there is a transformation from student to mentor, and with
it an acceptance of limitations and failure to reach certain goals. Issues of facili-
tation versus competitiveness and jealousy and the use of power and position
come into play. With age, the successful adult must also synthesize a work iden-
tity with the aging process and must be able to diminish the role of work in his
or her life as capacity progressively diminishes, and yet maintain self-esteem
and a capacity for pleasure. A stable identity can insulate an individual from
some of the narcissistic knocks of a decrease in work capacity. A major psycho-
logical challenge is associated with leaving the work force. No longer is the in-
dividual an accountant, a sales representative, or an electrician. The sense of self
so long linked to a career is gone, and the new retiree's challenge is to find al-
ternative ways to feel that life has purpose and meaning. Feelings of self-worth,
creativity, and nurturance must be sustained. Often, mentoring or volunteer work
provides opportunities for older people to pass on their expertise and wisdom.
Unfortunately, some individuals leaving the work force, as they work further
into old age, may withdraw and become even more self-absorbed. Conflicts in-
volving activity versus passivity become paramount.
In terms of sexuality, according to Michels (1980), the adult has two devel-
opmental tasks: to structure a pattern of sexual behavior that incorporates bio-
logical, psychological, and social reality, and to integrate that pattern with the
rest of his or her personality and to achieve maximal satisfaction from it. With
age comes increased pressure to redefine relationships to the partner, to care for
the partner in the face of illness and aging, to develop capacities for sharing
new activities, to continue an active sexual life, and eventually the capacity to
tolerate separation, loss, and death.
According to Erikson (1978), aging begins at conception but has special
characteristics at each phase of the life cycle. Jacques (1965) notes that the psy-
chological meaning of death is transformed in adult life from one of fear asso-
ciated with traumatic experience to one in which death begins to be more
familiar and gradually accepted. The actual loss of one's parents, friends, and
loved ones, as well as the inevitability of one's own death replaces the child's
unconscious fantasies as the symbolic equivalent of death. The social meaning
of adulthood and of being older must be integrated into the adult identity. With
development, the social impact of aging joins race, gender, and physical hand-
icap as roles that must be redefined and reintegrated into the identity.
An example of the integrative task of identity for the elderly is offered by
Erikson (1976) in his essay, "Reflections on Dr. Borg's Lifecycle," a commentary
on Ingmar Bergman's film Wild Strawberries. The film shows the journey of Isak
Borg, a 76-year-old professor driving through the Swedish countryside of his
youth to attend a public ceremony in honor of his enormous accomplishments.
The journey highlights poignant features of his developmental history. The coun-
tryside rekindles memories of his early years, as do hitchhikers of diverse ages
and personalities who enter and leave Borg's car during the course of his journey.
As Erikson points out, many of Borg's memories and thoughts revolve around the
40 Howard D. Lerner
last four stages in his life-cycle model (identity versus identification, intimacy
versus isolation, generativity versus stagnation, and integrity versus despair). Yet
Erikson points out that Borg experiences much more than his struggle with the
eighth developmental stage, the conflict between integrity and despair, out of
which wisdom is cultivated. As Dr. Borg struggles with the psychological issues
of this stage, he simultaneously grapples with issues from all the prior stages of
the life cycle. As Fitzpatrick and Friedman (1983) point out, Erikson converts his
life cycle model into a "life-spiral" model in which earlier developmental stages
are never even partially transcended or bypassed in development. That is to say,
the issues an individual struggles with in prior stages invariably reoccur along-
side new issues at later stages. Development is not thought to be primarily a lin-
ear progression but rather a spiral or mosaic in which multiple interactions
simultaneously link the past and the present. As each stage is negotiated, issues
from prior stages are simultaneously repeated but in different terms.
The Cognitive Dimension
As with all dimensions of adult development, the cognitive dimension un-

derlies and interdigitates with other dimensions in important and complex
ways. Nevertheless, for conceptual purposes it will be considered here sepa-
rately. An important cognitive transformation and development that is decisive
for the remainder of the life cycle takes place during adolescence. Thought of in
Piagetian theory (Inhelder & Piaget, 1958), this shift is from concrete to formal
operations. As Piaget (1954) asserts, the principle of formal operations in-
volves the real versus the possible. Formal operational thinking permits the
adolescent to progress from combining the properties of objects into classes to
combining classes into classes. Thus, the adolescent has access to a complete
system of all possible combinations. The system can be used to solve prob-
lems, to generate hypotheses, and to integrate identifications. Reversibility of
thinking frees the individual from the constraints of concrete reality. With this
accomplishment, adolescents and later adults can act on representations of re-
ality rather than on concrete reality itself. This transformation enhances adap-
tation in many ways. Formal operations permit enhanced freedom in dealing
with wishes, affects, and interpersonal relationships, and both the real and the
possible can be considered. Fantasy can become an adaptive and creative
modality. Affect-laden issues such as intimacy, death, and the meaning of life
can be considered: in the abstract; all possibilities and consequences can be
considered; and the internal world takes on the quality of a real place. These
cognitive developments permit increased freedom to experience a wider range
of both internal and external issues.
Beginning with adolescence and through adulthood to old age, with the
successful resolution of conflict and the struggle with crises, the individual can
experience his or her internal world in a more reflective and flexible manner
because an enhanced appreciation of the possible significantly reduces the fear-
ful aspects of internal stimuli. The shift from concrete to formal operations also
facilitates identity formation by affording the individual the cognitive capaci-
ties to organize and integrate representations of the past with those of the pres-
ent and the future. With certain progressive neurological illnesses as well as
regressions secondary to illness, depression, and psychological stresses and

strains, there can be a shift back from formal to concrete operations in the el-
derly. In many cases, with needed stimulation, empathic responsiveness, and
psychotherapy, these regressions can be reversed.
The Object Relations Dimension: Separation-Individuation

and Underlying Representations
In keeping with the hypothesis advanced by Colarusso and Nemiroff (1981)

that the fundamental issues of childhood continue as salient aspects of adult de-
velopment but in altered forms, several writers have examined the basic process
of separation-individuation through various phases of the life cycle, rather than
only as a significant event of childhood. According to Mahler (1973):
The entire life cycle constitutes a more or less successful process of distancing from an
introjection of the lost symbiotic mother. and external longing for the actual or fanta-
sized ideal state of self. with the latter standing for a symbiotic fusion with the all-
good symbiotic mother who was at one time part of the self in a blissful state of
well-being. (p. 138)
Colarusso and Nemiroff (1981) assert that the quest for enhanced differen-
tiation between self and other ends only with biological death. Formative adult
experiences, such as changing interpersonal relationships and investments, the
recognition of interdependence with others, the experience of parenthood and
grandparenthood, and the relationship with the spouse, all involve enhanced
separation-individuation secondary to the gradual acceptance of real over ide-
alized aspects ofrelationships and the acceptance of the aging process in both
self and others.
From a life-span perspective, there are important developmental changes
not only in the significance of interpersonal relationships but also in the sig-
nificance of being alone and maintaining an aloneness that is satisfying. The ex-
perience of comforting aloneness becomes increasingly important during the
second half of life, with the realization of the finitude of life (Jacques, 1965) to
some extent replacing contact with others as a source of solace and well-being.
The increased preference for solitude and aloneness must be understood as dif-
ferent from feelings of isolation. What may be more important in sustaining the
capacity for solace and comfort in aloneness are memories of time spent to-
gether in the past which draw upon an individual's internal representations of
themselves and other people. Drawing upon these representations, reminis-
cence replaces actual contacts with others as a major source of solace and self-
soothing in later adulthood and may become increasingly adaptive as the loss
of loved ones and impairment of mobility make actual contact more difficult.
The Structural Dimension: Ego Development
The structural dimension of development refers specifically to ego devel-

opment; that is, a complex and multifaceted set of psychological functions
based on interactions among innate constitutional givens, maturational forces,
42 Howard D. Lerner
and experiential and social influences. This dimension includes the innate de-
velopmental strengths and weaknesses of underlying cognitive and representa-
tional structures and of drive-affect modulating structures such as defenses.
Under optimal conditions, when these various functions operate effectively,
they facilitate adaptation and further development by freeing the individual
from conflict. The term "ego weakness" refers to either a diffusion or severe in-
hibition of drives and affects; there may be more pervasive regressions that im-
pinge on personality structures, and the vulnerable individual faced with such
threats to structural integrity may decompensate. Inhibitions include a limita-
tion of experience, of feelings and thoughts or both, a restriction of the experi-
ence of pleasure, a tendency to externalize internal events and negative
feelings, and a host of limitations of internalization necessary for the regulation
of impulses, affects, and thoughts, as well as limitations in the maintenance of
self-esteem. Naturally, for older people, experiences of physical illness, multi-
ple losses, and the specter of death pose a mature stress on the integrity of the
ego structure and exert a regressive pull.
Affect tolerance is considered an important aspect of the structural dimen-
sion. Although the intensity, depth, and range of affects can vary along both
qualitative and quantitative continua, both between individuals and across the
life span, more pathological expressions of affect tend to be less differentiated
and articulated. Level of development and structural integrity of the defensive
organization represents an important aspect of affect tolerance and expression.
Vaillant's (1977) longitudinal study of adaptation across the life span fo-
cused on defensive organization. Central to Vaillant's study is the assumption
that for individuals to master conflict adaptively and to utilize internal re-
sources creatively, adaptive styles, that is, defense mechanisms, must mature
and develop throughout the life cycle. Ordering defenses into a theoretical hi-
erarchy in terms of relative maturity, Vaillant found in a group of normal men
over time a progressive decline in less mature defense mechanisms of fantasy
and action and a concomitant increase in more mature defense mechanisms
such as suppression. He noted an increase in defenses such as sublimation and
altruism with age. Such changes in defensive organization provide evidence
that internal structural change occurs throughout the life span.
The Moral Dimension: Superego and Ego Ideal
Both psychoanalysis and developmental-cognitive psychology have made

important contributions to theories of moral development. Although traditional
psychoanalytic theory related moral development to psychosexual drive states,
cognitive psychology has been primarily concerned with moral judgment;
hence, the scope of cognitive theory is narrower than formulations derived from
psychoanalysis. Psychoanalytic inquiry has revolved around moral develop-
ment in terms of the socialization process and the progressive internalization of
standards that modulate potentially disruptive drives, and eventually, with the
development of the ego ideal, take the form of an integrated value system. On
the other hand, cognitive theorists have focused on the role of higher cognitive
processes and role-taking ability in moral judgment. Nevertheless, higher levels
of morality are thought to be inextricably contingent upon the achievement of

formal operations.
Psychoanalysts have approached moral development from the perspective
of transformations and consolidations of the superego. According to theory,
during adolescence external changes in relationship with the parents are paral-
leled by internal changes in the superego in terms of a revival of earlier con-
flicts. It is thought that these changes exert a disruptive and destabilizing effect
on self-regulation and self-esteem. Freud (1923/1957) thought ofthe superego
as a precipitate of the ego, consisting of identifications with the parents and re-
actions against them. According to Freud, functions of the superego including
judgment, prohibitions and injunctions, moral censorship, a sense of guilt and
social feeling, and identifications are all subsumed under the superego rubric.
According to modern structural theory, all compromise formations include a
superego or moral dimension, and the superego itself is understood as a com-
promise formation. These formulations all suggest that the moral dimension
and superego functioning in particular is a dynamic process that develops and
becomes transformed throughout the life cycle.
Transitional Objects
The work of D. W. Winnicott, a British object-relations theorist, has had a

major impact on psychoanalytic thought. Winnicott's formulations concerning
transitional objects and self-development have important implications for un-
derstanding development through the life cycle. It is in describing the infant's
experience of adapting to a shared reality through the transition from absolute
to relative dependence that Winnicott's most original and creative contributions
are made.
Winnicott (1951/1958) evocatively described the child's earliest experience
of decentering in efforts to bridge the gap between fantasy and reality. It was
through his deceptively simple and direct clinical observations that Winnicott
was led to the remarkable discovery of the child's first "not-me" possession,
that is, the "transitional object." Winnicott traced that transitional object (e.g., a
bundle of wool, the corner of a blanket, a teddy bear) to very early forms of re-
lating and playing. The relationship of the infant to the transitional object is
marked by several qualities, including a decrease in omnipotence, a relation-
ship in which the object is totally controlled by the infant, and in which the ob-
ject becomes the target for love and hate. The transitional object takes on a
reality of its own, combining the qualities of being paradoxically created and
discovered:
In the course of years it becomes not so much forgotten as relegated to limbo ... it is not
forgotten and it is not mourned. it loses meaning. and this is because the transitional
phenomena have become diffused. have become spread out over the whole intermedi-
ate territory between "inner psychic reality" and the external world as perceived by
two people in common. that is to say. over the whole cultural field. (p. 233)
Taking these formulations as a point of departure, Sugarman and Jaffe (1987)

claim that multiple developmental transitions occur throughout the life cycle;
44 Howard D. Lerner
the transitional phenomena are psychologically called upon and used to "regain
inner-outer equilibrium at each phase." In keeping with Winnicott's original for-
mulations, transitional phenomena are conceptualized as adaptive mechanisms
that are used throughout the life span. A core premise is that equilibrium be-
tween the individual and the environment is promoted through internalization
of key self-regulatory functions. Transitional phenomena are seen as central as-
pects of this process as they foster internalization. As a consequence, the "self
representation becomes increasingly differentiated and integrated through a se-
ries of internalizations" (Sugarman & Jaffe, 1987, p. 421). In essence, these au-
thors demonstrate how the transitional object facilitates modulation of tension
created by internal and external stresses throughout development.
The level of cognitive maturity and other dimensions of personality become
important in determining the manifest forms of transitional phenomena. As
other functions, including self and object representations, become increasingly
differentiated, transitional objects are thought to become increasingly less tan-
gible and more abstract. For example, in contrast to the transitional objects of
early childhood, the transitional phenomena of adolescence such as career aspi-
rations, music, and literature are more abstract, ideational, depersonified, and
less animistic. They increasingly approximate reality. Rather than the concrete
fantasy representation, it is ideas, causes, or symbolic value that become mean-
ingful. Regardless of the manifest content of transitional objects, transitional
phenomena are thought to promote the internalization of core self-regulatory
functions that include narcissistic regulation such as sustaining self-esteem,
drive regulation, superego integration, ego functioning, and interpersonal rela-
tionships. Through use of increasingly abstract transitional phenomena, the
individual is better able to synthesize discrepant events in his or her life experi-
ence. With increased development, the function of transitional phenomena also
changes from one of self-soothing to one of enriching the quality of life. For older
persons, in many ways sustaining memories, reminiscence, stories, and even
photos become important transitional phenomena.
Narcissism
One of the liveliest debates in contemporary psychoanalysis revolves

around the concept and nature of narcissism and its role in normal development.
Freud's use of the term left many areas of ambiguity that subsequent investiga-
tors have attempted to clarify. Stolorow (1975) offered a functional as well as
heuristic definition of narcissism: the "structural cohesiveness, temporal stabil-
ity and positive affective coloring of the self-representation" (p. 174). Psycho-
logical functioning is seen as narcissistic to the degree that it establishes and
maintains cohesiveness, stability, and positive affective coloring of the self.
Most authors use the term in the context of self-esteem. Normal narcissism has
been distinguished from pathological narcissism (Kernberg, 1976). Normal nar-
cissism is thought to depend on the structural integrity of the self-representation,
the achievement of self and object constancy, harmony between the self and
superego structures, the capacity to receive gratification from external objects,
and a state of physical well-being. Pathological variants of narcissism include a
defensive self-inflation with an associated lack of integration of the self-concept.

Whereas normal narcissism leads to sustained, realistic self-regard and mature
aspirations and ideals accompanied by the capacity for deep relationships,
pathological narcissism is accompanied by grandiose views of the self, a depen-
dency on the admiration of others, and poor object relations. It is manifested in
terms of a sense of entitlement, a pursuit of perfection, and impaired capacities
for concern, empathy, and love for others.
Although little has been written systematically about the vicissitudes of
narcissism throughout the life cycle, it is generally agreed that narcissism is ei-
ther altered or transformed as development occurs. Advances in the capacity
to love another suggests advances in narcissism. According to Spruiell (1975),
transformation of narcissism parallels transformations in object relations. Co-
larusso and Nemiroff (1981) use the term authentic self to characterize the ma-
ture adult, in that it describes the capacity to accept what is genuine within the
self and the outer world, regardless of narcissistic injury involved. According to
these authors, significant influences in later adulthood are narcissistic issues re-
lating to the aging body, the impact of aging on the time sense, and issues re-
lated to the loss of work and significant relationships.
Normative narcissistic regressions are precipitated by developmental tasks
and stresses such as the approach of mid-life, which often lead to a reemergence
of elements of more infantile forms of narcissism. The reworking and reintegra-
tion of aspects of infantile narcissism can be seen as an integral part of normal
development throughout the life cycle. In older persons. more infantile mani-
festations of narcissism can occur secondary to the loss of affirmation. calming,
and soothing from significant others. Of course, these experiences are more
prominent in those who depend on external reminders of their worth as a ma-
jor factor in maintaining their self-esteem and equilibrium. Among the painful
symptoms of "narcissistic injury" suffered by older persons are intense feelings
of emptiness, hypersensitivity to insult or lack of appropriate recognition, feel-
ings of inferiority, agitation. and exquisite feelings of vulnerability.
In each developmental phase throughout the life cycle, there are environ-
mental situations that are experienced as narcissistic stressors. Those situations
that are prone to cause more psychic pain in older persons include the loss of
significant objects and self objects; illnesses both of themselves and of others;
interpersonal difficulties, and a host of situations in the culture. including re-
location and economic hardship. To many elderly persons, the losses of people
who were important to them are the most difficult hardships to bear. Most
painful are those losses that involve significant others who were the source of
narcissistic supplies. It is for this reason that the experience of mourning and
one's capacity to bear it is a significant developmental task for older persons.
MOURNING
Loss is a pervasive experience in the normal developmental process. That

is, loss goes hand in hand with development. Pine (1985) has outlined four
losses that are thought to be normative. universal, and affectively powerful dur-
ing adulthood. During adulthood, in contrast to adolescence. there is a loss of
46 Howard D. Lerner
omnipotentiality: an awareness of limitations and roads not taken. A second

loss during adulthood is that of optimal body functioning and appearance. A
third loss is the progressive loss of one's own children that begins with the birth
of the child. The fourth and final loss during the adult period is the loss of peers
through death and the preparation for one's own death (the final step in loss of
body function and the loss of self and consciousness that goes with it).
Lerner and Lerner (1987) observed that Freud's original definition of mourn-
ing and its distinction from melancholia is still accepted by most psychoana-
lysts. According to S. Freud (1917/1951) the distinguishing mental features of
mourning are feelings of painful dejection, loss of interest in the outside world,
inability to love, and massive inhibition of all activity. Melancholia involves the
identical features as well as "a lowering of the self-regarding feelings to a degree
that finds utterances and self-reproaches and self-revelings and culminate in a
delusional expectation of punishment" (p. 244). Freud went on to note that
whereas melancholia, like mourning, may be a reaction to the loss of a loved
one, it differs in that "one cannot see clearly what it is that has been lost-[the
person] knows whom he has lost but not what he has lost in him" (p. 245). These
observations led Freud to conclude that "in mourning it is the world which has
become poor and empty; in melancholia it is the ego itself' (p. 246). If one sub-
stitutes the term "self' for "ego" these statements make phenomenological sense.
The process of mourning involves a gradual relinquishment and severing
of emotional ties to the lost object and a corresponding displacement of interest
or attachment onto other objects. According to Freud (1917/1951):
[Elach single one of the memories and situations of expectancy which demonstrate the
libido's attachment to the lost object is met by the verdict of reality that the object no
longer exists; and the ego. confronted as it were with the question whether it shall
share this state, is persuaded by the sum ofthe narcissistic satisfactions it derives from
being alive to sever its attachment to the object that has been abolished. (p. 237)
Melancholia also involves a withdrawal of interest or attachment from the

lost object. However, rather than being displaced onto other objects, the libido,
by means of regressive identification, is withdrawn back into the self. In this
way the object loss is transformed into a loss of self, and the conflict between
the self and the lost object is experienced as a "cleavage" within the self.
According to Lerner and Lerner (1987), the impact ofloss on personality is
dramatic, intense, complex, and dependent on a multitude of internal and ex-
ternal factors, including levels of separation-individuation, drive development,
level of defense, and, most significantly, the developmental level of mental rep-
resentations of self and other, as well as the availability of substitute objects and
the degree to which inner psychological structures have become autonomous
from supporting objects or self-objects. According to these authors, the impact
of object loss on object relations and narcissism can be viewed on a develop-
mental continuum in relation to self-object differentiation, level of mental rep-
resentation, and degree of self and object constancy. When these particular lines
of development are not fully structuralized or autonomous from supporting ob-
jects, the response to object loss is more likely to be one of melancholia; that is,
a loss of self as opposed to mourning a loss of the other.
George Pollock, more than any other psychoanalyst, has studied the
mourning process and has reported that this most poignant human experience
potentially serves as an adaptation to various losses throughout the life cycle.
According to Pollock, bereavement is only one dimension of mourning. Mourn-
ing can be set in motion not only after death, but also by loss, disappointment,
or change, and is a normative part of development throughout life. Colarusso
and Nemiroff (1981), quote Pollock (1979), who asserts:
Mourning is a universal transformational process that allows us to accept the reality
that exists which may be different from our wishes and hopes, which recognizes loss
and change, both externally and internally, and which ... can result in a happier life,
fulfilled and fulfilling for ourselves and for others. For the gifted the mourning process
may be part of or the end product that can result in creativity in art, music, literature,
science, philosophy, religion. (p. 10)
Mourning, seen in this vein, is an adaptive process that facilitates devel-

opment. According to Shabad and Dietrich (1989), death of the old gives way to
the birth of the new in ways that are not always immediately apparent in the
midst of grief. Loss, despite potentially pathogenic consequences, may also
have other creative, constructive, long-term consequences that are not always
recognizable in the immediate aftermath of death. The process of increased in-
ternalization of the representation of lost objects sets the stage for what Pollock
(1979) refers to as the mourning-liberation process. The pain of working
through the process of mourning can be gradually replaced by the relative psy-
chological freedom brought about by an acceptance that loss is final. A person
may then direct his or her creative capacities toward reconstituting a replace-
ment for the lost object (Shabad and Dietrich, 1989). The relative balance be-
tween acceptance of or denial of the finality of loss and death significantly
influences the individual's capacity to eventually work through and resolve the
loss experience.
The lifelong experience of separation and loss is what links mourning and
aging. Aging begins at conception but has unique characteristics at each phase
of the life cycle (Erikson, 1978). According to Michels (1980), aging means for
the first time a diminution of capacity and potential rather than the steady pro-
gressive growth associated with childhood. Michels states:
For the adult, death begins to be more familiar and gradually accepted. Friends and
loved ones die; one's own death is no longer beyond the psychologically meaningful
horizon of future time; and the inevitable diseases and disabilities of middle life begin
to replace the child's unconscious fantasies as the symbolic equivalent of death. (p. 33)
Compulsive attempts in middle age to remain young, hypochondriacal pre-

occupations with health in the parents, emergence of sexual promiscuity in or-
der to prove oneself youthful and potent, lack of authentic enjoyment of life,
and frequency of religious concern in middle age are familiar defensive patterns
of coping with the inevitability of death (Jacques, 1980). The aging process, and
with it, loss of physical and mental capacities, can represent an adult life crisis.
It intensifies narcissistic vulnerability, recognition of mortality, and the in-
evitable approach of death, which demands adaptation to this most imminent
threat and stress. Dealing with the issue of death itself, both for the individual
48 Howard D. Lerner
approaching it, as well as survivors, involves a major shift in internal, interper-

sonal, and social factors and the need for psychological adaptations to new cir-
cumstances. Mourning and the aging process require a continuing evolution
and maturation in order to maintain adaptation and functioning. Inevitably, the
vicissitudes of life experience increasingly include separation, loss, and mourn-
ing. And no one is immune to them. Positive adaptation to these inevitable life
experiences are less related to their existence than to the individual's capacity
for conflict resolution and continued adaptation. These adaptations are results
of the multiple dimensions or lines of development considered in this chapter.
SUMMARY
Recent contributions to psychoanalytic theory have begun to examine and

refine multiple dimensions of development as they extend across the life cy-
cle. Several authors have offered formulations as to how individuals deal with
the ongoing developmental task of separation-individuation in the adult years
approaching old age. In line with the approach of such contributions, this chap-
ter, in exploring multiple dimensions of development in old age, has sought to
integrate the formative, ongoing influences of intrapsychic processes with the
continuous impact of maturation and life experience. Evolution of the various
dimensions of development during the later years will be of increased interest
to psychoanalysts as the "baby boomers" approach later stages of adulthood.
Continued work will be done on the impact that specific life experiences exert
on adult development. Too often, researchers and theorists formulate signifi-
cant life experiences of adulthood, such as close relationships, divorce, loss,
and illness, outside the context of an individual's ongoing development. This
makes it easy to lose sight of the multiple dimensions of development that pre-
stage each adult experience. Further, we fail to consider the role that each new
experience of later adulthood potentially plays in the refinement and reorgani-
zation of previous dimensions of development. Individual experience thus be-
comes static and detached. It is important to understand how an individual's
ongoing development sets the stage for a particular life event and then is trans-
formed by it. Our understanding of critical life experiences during old age, for
example, retirement, grandparenthood, illness, the loss of a spouse, and prepa-
ration for the loss of one's self, can be greatly enriched by viewing such experi-
ences in the context of multiple dimensions of development.
REFERENCES
Behrends. R. S.• & Blatt. S. J. (1985). Internalization and psychological development throughout the
life cycle. Psychoanalytic Study afthe Child. 40, 11-40.
Blatt. S. J. (1974). Levels of object representation in anaclitic and introjective depression. Psycho-
analytic Study a/the Child, 29,107-157.
Boesky. D. (1989). A discussion of evidential criteria for therapeutic change. In A. Rothstein (Ed.).
How does treatment help: Modes of therapeutic action of psychoanalytic therapy. Madison.
CT: International Universities Press.
Brenner, C. (1986), Reflections. In A. Richards & M. S. Willock (Eds.), Psychoanalysis: The science
of mental conflict. Essays in honor of Charles Brenner. Hillsdale, NJ: Analytic Press.
Colarusso, C. A., & Nemiroff, R. A. (1981). Adult development. New York: Plenum.
Erikson, E. (1976). Reflections of Dr. Borg's lifecycle. Daedalus, 105, 1-28.
Erikson, E. (1978). life history and historical moment. New York: Norton.
Fitzpatrick, J. J., & Friedman, 1. J. (1983). Adult developmental theories and Eric Erikson's lifecy-
cle model. Bulletin of the Menninger Clinic, 47, 401-416.
Freud, A. (1965). Normality and pathology in childhood. New York: International Universities Press.
Freud, S. (1951). Mourning and melancholia. In J. Strachey (Ed. and Trans.), The standard edition
of the complete psychological works of Sigmund Freud (Vol. XIV, pp. 237-258). London:
Hogarth Press. (Original work published 1917).
Freud, S. (1951). Three essays on the theory of sexuality. In J. Strachey (Ed. and Trans.), The stan-
dard edition of the complete psychological works of Sigmund Freud (Vol. VII, pp. 125-243).
London: Hogarth Press. (Original work published 1905).
Freud, S. (1957). The ego and the id. In J. Strachey (Ed. and Trans.). The standard edition of the
complete psychological works of Sigmund Freud (Vol. IX, pp. 12-68). London: Hogarth Press.
(Original work published 1923).
Gedo, J., & Goldberg, A. (1973). Models of the mind. Chicago: University of Chicago Press.
Guntrip, H. (1974). Psychoanalytic object relations theory: The Fairbairn-Guntrip approach. In S.
Arieti (Ed.), American handbook of psychiatry (Vol. 1). New York: Basic Books.
Harman, S. W. (1978). Male menopause? The hormones flow but sex does slow. Medical World, 20, 11.
Inhelder, B., & Piaget, J. (1958). The growth of logical thinking from childhood to adolescence: An
essay on the construction offormal operational structures. New York: International Universi-
ties Press.
Jacques, E. (1965). Death and the mid-life crisis. International Journal of PsychO-Analysis, 46,
502-514.
Jacques, E. (1980). The mid-life crisis. In S. Greenspan & G. Pollock (Eds.), The course of the life
cycle: Psychoanalytic contributions toward understanding personality development Vol. 3,
pp. 1-24). Washington, DC: National Institute of Mental Health.
Kernberg, O. (1976). Borderline conditions and pathological narcissism. New York: International
Universities Press.
Klein, G. (1976). Psychoanalytic theory: An exploration of essentials. New York: International Uni-
versities Press.
Kohut, H. (1971). The analysis of the self New York: International Universities Press.
Kohut, H. (1977). The restoration of the self New York: International Universities Press.
Lerner, H. (1987). Psychodynamic models of adolescence. In M. Hersen & V. Van Hasselt (Eds.),
Handbook of adolescent psychology (pp. 53-76). New York: Pergamon.
Lerner, H., & Ehrlich. J. (1992). Psychodynamic models. In V. Van Hasselt & M. Hersen (Eds.), Hand-
book of social development: A lifespan perspective (pp. 51-79). New York: Pergamon.
Lerner, H., & Lerner, P. (1987). Separation, depression, and object loss: Implications for narcissism
and object relations. In J. Bloom-Feshbach & S. Bloom-Feshbach (Eds.), The psychology of sep-
aration and loss (pp. 375-395). San Francisco: Jossey-Bass.
Mahler, M. (1973). The experience of separation-individuation in infancy and its reverberations
through the course of life: Infancy and childhood (panel report). Journal of the American Psy-
choanalytic Association, 21, 135.
Mahler, M., Pine, F., & Bergman, A. (1975). The psychological birth of the human infant. New York:
Basic Books.
Martin, C. E. (1977). Sexual activity in the aging male. In J. Money & H. Musaph (Eds.), Handbook
of sexology. Amsterdam: Elsevier/North Holland.
Michels, R. (1980). Adulthood. In S. Greenspan & G. Pollock (Eds.), The course of the life cycle: Psy-
choanalytic contributions toward understanding personality development. (Vol. 3, pp. 25-34).
Washington, DC: National Institute of Mental Health.
Muslin, H. (1992). The psychotherapy of the elderly self New York: Brunner/Mazel.
Neugarten, B. (1979). Time, age, and the life cycle. American Journal of Psychiatry, 136, 887-894.
Piaget, J. (1954). The construction of reality. New York: Basic Books.
Pine, F. (1985). Developmental theory and clinical process. New Haven, CT: Yale University Press.
50 Howard D. Lerner
Pollock. G. (1979). Aging or aged: Development or pathology? Unpublished manuscript.

Settlage. C. F.• Curtis. J.• Lozoff. M .• Silbershatz. G.• & Simburg. E. (1988). Conceptualizing adult de-
velopment. Journal of the American PsychoanaJytic Association. 36. 347-369.
Shabad. P.• & Dietrich. D. (1989). Reflections on loss. mourning. and the unconscious process ofre-
generation. In D. Dietrich & P. Shabad (Eds.), The probJem of loss and mourning (pp.
461-470). Madison. CT: International Universities Press.
Spruiell. V. (1975). Narcissistic transformation in adolescence. International Journal of Psychoana-
lytic Psychotherapy. 4. 518-535.
Stolorow. R. (1975). Toward a functional definition of narcissism. International Journal of Psycho-
analysis. 56. 179-185.
Sugarman. A .• & Jaffe. 1. (1987). Transitional phenomena and psychological separateness in schizo-
phrenic. borderline. and bulimic patients. In J. Bloom-Feshbach & S. Bloom-Feshbach (Eds.).
The psychology of separation and loss (pp. 416-458). San Francisco: Jossey-Bass.
Sugarman. A .. Bloom-Feshbach. J.• & Bloom-Feshbach. S. (1980). The psychological dimensions of
borderline adolescence. In J. Kwawer. H. Lerner. P. Lerner. & A. Sugarman (Eds.). Borderline
phenomena and the Rorschach test (pp. 469-494). New York: International Universities Press.
Vaillant. G. E. (1977). Adaptation of life. Boston: Little. Brown.
Waelder. R. (1930). The principle of multiple function: Observations on overdetermination. In S.
Guttman (Ed.). Psychoanalysis: Observation. theory. application (pp. 68-83). New York: In-
ternational Universities Press.
Winnicott. D. (1958). Transitional objects and transitional phenomena. In D. Winnicott (Ed.). Col-
lected papers: Through pediatrics to psychoanalysis (pp. 229-242). New York: Basic Books.
(Original work published 1951)
CHAPTER 4
The Value of Behavioral

Perspectives in Treating
Older Adults
LARRY w. DUPREE AND LAWRENCE SCHONFELD
INTRODUCTION
Behavioral approaches used in the treatment of older adults have now been im-
plemented and evaluated over about a 25-year period. The field of behavioral
gerontology, as it is known, is noted by Wisocki (1991) to be "best defined as the
application of behavioral principles and procedures to the problems of the el-
derly and the issues of aging" (p. 3). Interventions based on these principles
have proven to be among the most effective treatments for a wide variety of be-
havior problems for all age groups.
In this chapter, we discuss three models for explaining behavior problems,
the advantages of behavioral interventions in overcoming "ageism," and the
value of the behavioral perspective at various stages of the intervention process
(case finding, assessment, intervention, and outcome). In addition, we discuss
the advantages for treatment staff and the problems they often encounter in us-
ing behavioral approaches.
CONCEPTUALIZING THE PROBLEMS OF OLDER ADULTS
Three common models used in conceptualizing behavior problems have

important implications for the assessment and treatment of older adults. The
medical, social, and behavioral models are all deterministic in that behavior is
believed to be influenced by previous events.
LARRY W. DUPREE AND LAWRENCE SCHONFELD • Department of Aging and Mental Health, The Florida
Mental Health Institute, University of South Florida. Tampa. Florida 33612-3899.
51
52 Larry W. Dupree and Lawrence Schonfeld
The medical model considers deviations from normal functioning as due to

illness or disease, most notably improper physiological functioning that pur-
portedly occurs as a natural (and expected) consequence of aging. Advocates of
the medical model assume that an underlying cause such as a biologically
based disease or an unobservable psychological process leads to the behavior
problems or "symptoms." In this regard, Estes and Binney (1989) describe the
dangers of the "biomedicalization of aging" (i.e., the powerful influence the
medical field has on the process and problems of aging). This not only places
treatment under the domain of biomedicine, but also leads to assumptions that
behaviors are difficult to change, biologically determined, and possibly irre-
versible. Such assumptions easily interact with insidious ageism to markedly
influence case finding, assessment, and intervention.
The social model attributes changes in behavior or differences in behavior
between older and younger adults to different roles assigned to each of these
age groups by the culture or society. We tend to expect less responsibility and
decreased functional ability in our society's older members. Miller (1979) noted
that we accept (and expect) lesser levels of functioning in these specific areas:
self-care behavior, task behavior, and relationship behavior.
According to the behavioral model, behavior is the product of learning, pre-
ceded by antecedent events and followed by consequences or reinforcers. As one
ages, changes in both the antecedent and the consequent events are associated
with changes in behaviors (M. M. Baltes & Barton, 1977; Patterson & Jackson,
1980a, 1980b). In response to newer environmental antecedents and conse-
quences, some appropriate behaviors are gradually lost, and other (perhaps in-
appropriate) behaviors appear. Within this model, behavior is assessed,
evaluated, and validated through direct observation, rather than theoretically
based. The approach is problem-oriented rather than age-specific and appears to
be applicable to many of the well-documented problems noted in later life.
It should be noted that although behaviorists concentrate on nonmedical
determinants of behavior change, behavioral gerontologists are aware that, in
comparison to younger adults, older adults more frequently experience physi-
cal illness, dementia, stroke, or medication side effects, all of which may in-
fluence behavior. Older adults should have both behavioral and medical
evaluations to determine the separate or combined influences of these prob-
lems. In most cases, behavioral interventions can be used concurrently with
medical interventions.
ADVANTAGES OF
THE BEHAVIORAL APPROACH
Use of the behavioral approach avoids many of the stereotypes, biases, and
unfounded assumptions known as "ageism" that negatively impact the delivery
of mental health services to older adults. Ageism reflects a personal revulsion
to, and distaste for, growing old, and a fear of powerlessness, "uselessness," and
death. Older adults themselves, as well as family members and others in their
community, demonstrate stereotypic beliefs which can act as barriers to asking
The Value of Behavioral Perspectives in Treating Older Adults 53
for mental health care (Bernstein, 1990; Butler, 1980; 1. W. Dupree. O'Sullivan,
& Patterson, 1982). Mental health professionals may also exhibit ageism by
equating aging with inevitable decline. being pessimistic about the likelihood
and speed of change, believing that it is futile to invest effort in a person with
limited life expectancy, or assuming that behavioral change is a one-to-one cor-
relate of physical change (M. M. Baltes & Barton, 1977; Gatz & Pearson, 1988;
Patterson & Dupree, 1994).
Because the behavior therapist usually explores the possibilities of factors
other than age and physiological changes as underlying behavior. the notion of
reversibility of functional age decrements and apparent cognitive impairment
remains viable until proven otherwise (M. M. Baltes & Baltes, 1977; Baltes &
Barton, 1977; P. B. Baltes & Willis, 1977; Hoyer, Mishara, & Reidel, 1975; Pat-
terson & Jackson, 1980a, 1980b; Rebok & Hoyer, 1977). Almost 20 years ago,
Cautela and Mansfield (1977) reported that, "even when organic dysfunction is
noted it can be of practical value to assume that many behaviors can be modi-
fied somewhat by applying specific behavior therapy procedures regardless of
past history or organic involvement" (p. 23). The cultural notion of behavioral
inflexibility often attributed to the elderly becomes an empirical question rather
than a "fact." Such an empirical approach has resulted in doubts as to the gen-
eral validity of a biological decrement model (M. M. Baltes & Baltes, 1977;
M. M. Baltes & Barton, 1977; P. B. Baltes & Willis, 1977). Thus, in directing the
treatment specialist to consider factors other than age, the behavioral model has
long permitted, and has even prompted, an optimistic attitude regarding the
mental health problems of older people. Problems are defined in terms of oc-
curring behavior, and are treated on the assumption that they can be remedied.
Cautela and Mansfield (1977) noted additional benefits of the behavioral
model for the problem behavior of the elderly: (1) time is not unnecessarily
spent on determining the "true" impact of all past life experience, (2) present
behavior is the target for change (rather than seeking some unconscious moti-
vator of behavior), (3) older individuals profit more from active therapists and
treatment involving problem-oriented behavior rehearsal (as opposed to the
more passive insight therapy), and (4) negative diagnostic labels are applied
less frequently. Such labels, particularly when applied to older adults, are
rarely removed, and often lead to less than enthusiastic efforts to change the un-
wanted behavior of the older adult.
The behavioral model is also useful in the treatment of older individuals
in terms ofits cost effectiveness, its replicability or consistency of treatment or
both, the value of negative results as well as positive, the structure it affords
staff in attending to individuals in treatment, and its potential for contribut-
ing to suitable community placement based on individual circumstances. For
example, Dupree and his colleagues (1. Dupree, 1994; L. Dupree, Broskowski,
& Schonfeld, 1984; Patterson et al., 1982) described group "modular" ap-
proaches with monitoring that helps to ensure that today's validated program
is tomorrow's. Treatment modules have defined objectives, defined and oper-
ationalized teaching techniques and materials, specific assessment techniques,
and a module manual to support a high level of standardization. These char-
acteristics permit consistency over time even with staff turnover or various
levels of staff training and disciplines. Module standardization also permits

replication of the modules in state psychiatric facilities and community men-
tal health centers.
Modular activities are conducted in groups for reasons of economy and ef-
ficiency. Staff are trained to criterion (i.e., ability to lead in accord with man-
ual standards). The daily availability of module manuals to staff greatly aids in
sustaining the program-sanctioned philosophy, content, and methodology.
Again, consistency and continuity (regardless of the therapist present) can be
maintained for an organization in both good and bad times. Elderly clients per-
ceive that same continuity as well. Thus, the value of structured behavior ther-
apy to any treatment program is a sense of quality control including treatment
stability over time and replicability both within and outside the program. Also,
a group module can be used with other standardized units to form an integrated
program (L. Dupree, 1994).
When budgets for mental health services are cut. often the first services that
are reduced or eliminated are those specifically for older rather than younger
adults (Kimmel. 1988). The potential value of modularized approaches for older
people increases as these resources become limited.
An often overlooked value of operant-based intervention is that it requires
observation on the part of those who are involved in the treatment plan. The
frequent attention of staff and others is intentionally directed toward individu-
als' behavior. By using basic learning principles and structured interventions,
such as a token economy system. treatment specialists can be "forced" to attend
to targeted behaviors and then function as both providers of tokens and social
reinforcers. Richards and Thorpe (1978) also report studies in which behavioral
techniques were successfully applied to the behavior and attitudes of treatment
staff caring for older adults in institutional settings.
The behavioral perspective assumes that human behavior is alterable. or
that the problem behavior is reversible, until empirically demonstrated other-
wise. Such an approach attends to concrete events (deficits and excesses,
strengths and weaknesses, antecedents and consequences) as explanations for
behavior rather than invoking constructs or labels. It does not overly rely on
physical entities as the basis for behavior. The smallest units of analysis in rel-
evant diagnostic interviewing of an elderly individual are the mutual and in-
terdependent relations between the individual and his or her environment
(Rebok & Hoyer. 1977). Mahoney (1975) asserts that it is more productive to ex-
amine the nature of the interdependence than to maintain that one's internal
environment has greater effect on behavior than does the external environment.
Even though physical changes may account for some part of any loss of en-
vironmental competence, using a strictly physical model of aging and the
diagnostic process based on such an approach is not appropriate. Indeed, the
physical model is biased against intervention with older adults by assuming an
irreversibility of behavior (purportedly based on aging-related, irreversible
physical changes).Finally, the precision or clarity of most information produced
in treatment programs emphasizing the behavioral model is also valuable rela-
tive to client placement. For example, if an individual does not know what
medications to take, when to take them, and, even with continued training and
assessment, never significantly improves over baseline, then the community
placement setting should provide enough structure and assistance to ensure

that that individual is prompted to take it properly.
CATEGORIES OF BEHAVIORAL
APPROACHES
There are three broad categories of behavioral approaches. The first, behav-
ior modification or therapy, focuses on observations of overt behaviors and the
application of learning and conditioning principles to modify the behavior in
question (Powers & Osborne, 1976; Spiegler & Guevremont, 1993). Overt behav-
iors are those easily observed by the client, family member, therapist, or staff. The
second category, self-management techniques, involves teaching the client to use
behavior modification strategies to modify his or her own behavior (either overt
or covert). The third category, cognitive-behavioral therapies, involves modifica-
tion of covert behaviors or private events that only the client can observe.
BASIC BEHAVIOR MODIFICATION
Individuals who are retired, widowed, and living alone may experience sig-
nificant mental health problems that are not noticed by service providers or fam-
ily members. In comparison to their proportion of the general population, older
adults underutilize mental health services, such as community mental health
centers or psychotherapists in independent practice (Knight, 1986; Lebowitz,
1988). Lasoski (1986) suggested that this underutilization may be the result of
misassumptions about irreversibility, ageism, transportation problems, lack of re-
ferral, lack of outreach, organizational barriers, or even the attitudes of the elderly
about mental health services (i.e., stigma of mental illness, fears about the conse-
quences). Assuming that someone brings the problem behavior to the attention of
a mental health professional, the next task is for that professional to (1) determine
whether it is a high-frequency problem behavior, and (2) define the behavior. Be-
havior is considered maladaptive when it is urgent, of a high frequency, and af-
fects some quality of life of the individual, the person's family, or significant
others. In extreme cases, that behavior may place the person at risk of being trans-
ferred to another living environment or becoming institutionalized.
The Assessment Process
Once the problem behavior is brought to the attention of the therapist. he or

she must begin the process of assessment (Le., to understand what events pre-
cede and follow the behavior). The older adult's adaptive behavior should be as-
sessed relative to actual daily living tasks (DeNelsky & Boat, 1986; Goodstein,
1980; Kaszniak, 1990; Lawton, Whelihan, & Belsky, 1980). The delineation of
specific behavioral and environmental deficits should demonstrate the type and
degree of support needed for maintaining residence in the surroundings in
which the person is assessed (Lawton, 1986; Patterson & Dupree, 1994).
What we are most often interested in understanding and measuring with

regard to older clients are environmental interactions that "support' (Le.,
prompt, reinforce, or otherwise help to maintain) maximally independent, or-
ganized, and generally adaptive behaviors. Consistent with our previous dis-
cussion, the focus is on person-environment interactions. This approach is
quite different from more common approaches that treat the elderly person as
a mere passive recipient of supports.
A comprehensive behavioral interview can generate information about
deficits and supports that more directly explains behavior and that needs less
specialized or "expert" interpretation (Patterson & Dupree, 1994). In contrast,
psychometric data require sophisticated interpretation and interpretive com-
ments, resulting in evaluation reports based on secondary data or norms. These
norms discount the uniqueness of the older person's behavior in his or her par-
ticular context. However, this discounting can be countered by using structured
behavioral interviews that guide the clinician over specified life domains.
In summary, any reasonable assessment approach relative to an elderly in-
dividual must ameliorate cultural and professional ageism (Meeks, 1990), as-
sess diverse areas of the older person's life, and highlight both internal and
external antecedents for the expressed problem behaviors. For older adults, ap-
propriate assessment is on a broader scale than for many younger populations,
and positive change is based on a broad assessment of strengths and deficits.
The essential diagnostic product is an indication of the older person's capacity
to do things required in his or her own environment. This incorporates the no-
tion of "age-free" assessment, a value to older adults.
Problem Definition
The product of the assessment process is the definition of the problem be-
havior. A good definition is objective in that the behavior can be verified by ob-
servations of the therapist and significant others over a specified period of time
with data recorded in terms of frequency, duration, magnitude, antecedents,
consequences of the behavior, and so on. The principle of parsimony should be
used to guide the process leading to definition of the problem. This principle
suggests that whenever a therapist has a choice between a simple explanation
suggested by observable events or a more complex explanation perhaps based
on unobservable events, the therapist should choose the simpler explanation,
leading to fewer assumptions and more conservative interpretations.
Although it is tempting to rely on a DSM-IV diagnosis (American Psychi-
atric Association, 1994), or to define a problem in terms of theoretical constructs
such as "depression," a behavior therapist must define the problem behavior in
terms of the observed behaviors (e.g., "does not participate in group activities,"
"client observed crying when asked to talk about family issues," "the client
makes frequent negative self-statements"). Problem definition is critical to the
evaluation of more immediate and future (posttreatment) success. By defining
behaviors in specific, parsimonious terms that require data and objective obser-
vation, rather than speculating about underlying motives, the client's success in
treatment (Le., change in targeted problem behavior) can be evaluated. When
staff are in doubt about operationally defining a problem, we suggest that they
consider the question: How will you know when there is improvement in the
problem? To answer this question, the staff member must consider overt, ob-
servable behaviors, rather than theoretical constructs or diagnostic categories.
After operationally defining a problem, staff observe the client's unwanted
behavior to determine what events precede it (antecedents) and what events fol-
low that behavior (consequences). Consequences reveal the potential rein-
forcers that maintain the behavior. Thus, the observations allow the therapist to
construct a behavior chain of antecedents-behavior-consequences or "A-B-C's."
Finally, after the behavior is defined, the type of data to be recorded becomes
evident. In most cases, it is the frequency of a behavior: however, in other cases,
it may represent magnitude or intensity (e.g., how loud a person yells when dis-
rupting a group), or duration (the length of the behavior episode) or both. Once
the measure can be determined, staff can proceed with baseline observations.
Baseline
Following identification of the problem and prior to implementing treat-

ment, the therapist conducts baseline observations. The therapist allows suffi-
cient time and observations to establish a baseline level (pattern) of the
behavior. This is especially important for older adults who are admitted to new
residences or facilities. Should a treatment plan be implemented while the per-
son becomes oriented to the new environment, any resulting change in behav-
ior may be falsely attributed to the treatment. Thus, determining when a
"stable" baseline is reached depends on many factors: frequency of the behav-
ior, the conditions under which it occurs, and the projected length of treatment
(or length of stay in a residential treatment program). Stability in the frequency
of a behavior might be considered a fluctuation of no more than a certain per-
centage from the average behavior of, for example, five consecutive observa-
tions of the behavior during specified periods of time.
Development of Treatment Goals
The goal of treatment is the development of alternative behaviors that are

socially acceptable and adaptive, rather than simply the application of condi-
tioning principles to reduce maladaptive behaviors (Powers & Osborne, 1976).
Treatment goals should be developed as early in the process as is feasible.
Short-term goals, such as those met between case reviews or treatment team
meetings, are modified as progress toward the target behavior is assessed. Long-
term goals remain relatively consistent and often reflect the final behavioral
goal after intervention ends.
Our observations of staff from geriatric units of state psychiatric hospitals
and other treatment facilities suggest that staff believe they are "required" by
policy to develop goals and treatment plans to eliminate or reduce maladaptive
behaviors. Consequently, they frequently ignore goals focusing on the devel-
opment of new, more adaptive behaviors. For example, a client in a residential
facility may be observed returning to his or her bedroom rather than participat-
ing in activities. Staff may list the goal as "decrease the number of times per day
the client is observed in bedroom." In another example, the client may be ob-
served as "yelling obscenities when asked to attend group treatment" with the
goal being to decrease the yelling and obscenities. When such goals are identi-
fied, they often lead to the use of punishment techniques, such as seclusion or
removal of privileges, to suppress maladaptive behaviors.
In working with such staff, we pose two key questions they should answer
before developing treatment goals and plans: What positive, adaptive behavior
is expected to replace the maladaptive behavior? and What skill must the client
learn to improve functioning and be discharged successfully? Rather than fight-
ing their perceptions of what the program policies should be (Le., listing only
suppression of behavior as a goal in the written treatment plan), we found that
it was helpful to ask staff to develop a second goal in the client's treatment plan,
identifying the new, "replacement" behavior. Thus, in the examples provided
above, we might list the adaptive goal as "increase group participation" or "de-
velop conversational skills."
Finally, the question of how the client participates in the development of
the treatment goals and plan is extremely relevant given current concerns for
consumer rights, licensure requirements, and accreditation policies. Tradition-
ally, with basic behavior modification approaches, the treatment staff decided
the methods of observation, treatment, or reinforcement, and so on, with little or
no input by the client. Informing a client about the plan may have been per-
ceived as awkward or even in conflict with unobtrusive observation. Today,
most guidelines emphasize a more active client role by requiring a written plan
and staff documentation of how the person was informed and involved in the
process. This can be accomplished in day treatment and residential programs by
inviting the person, guardian, and significant others into the treatment team
meeting. However, if the person feels uncomfortable or "confronted" by the pro-
fessionals, the therapist and the client can meet and identify problem behaviors
that they believe should be high priority. The therapist, after meeting with the
treatment team, can then respond to the client regarding the specifics of the plan.
Active participation by the client in the treatment planning process may
make unobtrusive observation difficult. However, informing the person of the
future consequences of behaviors may accelerate the modification of his or her
behavior. Further, for older adults in outpatient treatment, it is essential that the
therapist and client work closely together in developing goals and implement-
ing and evaluating treatment. Providing clients with feedback as to their pro-
gress (verbal reports, graphs of their behavior) is a valuable form of positive
reinforcement. The written treatment plan, which indicates who is responsible
for what, will serve a similar function as a behavioral contract.
Implementing the Behavior Modification Program

Behavioral techniques have proven effective for many older clients who are
deficient in activities of daily living or social skills. Patterson and colleagues
(1982) describe a variety of techniques used to teach older adults adaptive be-
haviors, by delivery of reinforcement contingent upon the observation of the

target behavior or, in the case of a shaping procedure, a reasonable approxima-
tion of the target behavior. For example, using a token economy, very simple
skills, such as time conversing with other people, can be increased by provid-
ing tokens and praise after certain intervals of time in which staff observe such
behavior. More complex skills (e.g., maintaining a household) may require di-
dactic methods, modeling, prompting, and so on, to teach sequences of behav-
ior, after which reinforcement follows.
According to the Law of Effect, response-contingent positive reinforcement
increases the probability of certain behaviors (goals), whereas response contin-
gent punishment (e.g., removal ofreinforcers, time-out) decreases the probabil-
ity. Our experience in training staff from geriatric treatment units in state
psychiatric hospitals suggests that staff more easily identified and used aversive
procedures than positive reinforcement. In conjunction with an overemphasis
on suppression of behavior, this led to increased use of seclusion, restraints, or
geri -chairs; overreliance on medications to control behavior; or removal of unit
privileges. Referring to the earlier example, staff believed they resolved the
problem of the clients' returning to their rooms during daytime hours by lock-
ing the bedrooms during those hours. As a result, instead of becoming active or
involved in unit activities, some patients lay on the floor in the halls or in day
area rooms, while others sat passively in chairs around the perimeter of the ac-
tivity room. To address this issue, we suggested that staff use the Premack prin-
ciple (Premack, 1962) to increase adaptive behaviors. This principle states that
a behavior that has a high probability of occurrence (e.g., going to the bedroom)
can be used as a reinforcer for a low-probability behavior. By asking the key
questions noted earlier, staff easily determined that it would be desirable for the
client to participate in group treatment. Using the Premack principle, the client
could be informed that if he or she met a minimal criterion of group partic-
ipation (e.g., 10 minutes), he or she would be free to choose to return to the
bedroom later. On future trials, the amount of time required for earning re-
inforcement is increased and time spent in the room decreased.
One of the problems encountered by staff in geriatric units is difficulty in
identification of reinforcers. For example. staff may inadvertently reinforce
and maintain maladaptive behavior such as yelling or screaming by paying at-
tention to that behavior, but paying little or no attention to the individual
when he or she is calm and sociable. Staff may also assume that what is re-
inforcing for them is also reinforcing for everyone else. However, for some peo-
ple, the administration of candy, tokens (in a token economy), or additional
unit privileges may not be motivating. Determination of appropriate positive
reinforcement requires interaction with and observation of each individual.
Many older adults in mental health facilities have responded well to the use of
praise or by being rewarded with conversation with a staff member in whom
they have shown interest.
Even when appropriate reinforcers are identified, people can become sati-
ated with reinforcement. It is helpful for staff to identify a menu of reinforcers
prior to the development of a treatment plan in order to shift to another when
satiation occurs. We encourage the staff to spend extra time observing how their
older clients spend much of their time while on the unit, to ask them or their
families about the activities they enjoy, and to experiment with the use of praise
and social contact as potential reinforcers.
Evaluation of the Treatment Plan
Evaluation of the treatment plan is an ongoing process. During the assess-

ment phase, the type of data to be recorded is determined (e.g., frequency, du-
ration, magnitude). As treatment progresses and criteria are met, the plan can
be altered to make the short-term goals more similar to the long-term goal. Rel-
ative to the earlier example, there would be an increase in group participation
or other adaptive skills, with a simultaneous decrease of the maladaptive
behaviors.
In the simplest form of evaluation, using single case analyses, a therapist
will measure the rate or level of the target behavior during baseline ("A") and
compare it to that during the treatment ("B"). Also, effectiveness of treatment
can be evaluated by removing the treatment conditions (Le., a return to the
baseline condition). If the behavior returns to its former, pretreatment level,
then the therapist can state that the treatment was the most likely cause of the
change. However, because therapists wish to discharge the patient success-
fully, a typical design will be an ABAB design in which the final phase of treat-
ment is a second implementation of treatment, or more practically, a variation
of the treatment that prepares the client for discharge and appropriate behav-
ior in his or her environment (e.g., fading the treatment over time, gradually re-
ducing the number of reinforcers, adding new reinforcers likely to be found in
the community).
Assessment of skill deficiencies that create barriers to successful commu-
nity placement and independence is critical for evaluation at admission, to as-
sess progress, and to determine discharge readiness. Staff must respond to the
questions, How can we demonstrate that the individual is improving relative to
the identified problem behavior as the result of this intervention? and, Is this
person behaviorally capable of managing the circumstances of his or her extra-
treatment environment? or, Has he or she acquired necessary skills and behav-
iors? We encourage staff to graph data when feasible to determine changes or
stability in the measured target behavior, and to demonstrate to staff and to the
client that changes in behavior have or have not taken place. People often tend
to believe that if they have not accomplished the final target behavior in its en-
tirety, they have failed. To counteract this notion, it is suggested that even small
improvements in behavior should be highlighted in discussions with the client
to encourage further progress.
BEHAVIORAL INTERVENTIONS DEVELOPED

IN FLORIDA
Thus far, we have posed several questions to help staff define target behav-
iors and implement the plan: (1) How do we know a problem exists? (2) How
will you know when there is improvement in the problem? (3) What positive,
adaptive behavior is expected to replace the maladaptive behavior? (4) What

skill should the client learn to improve functioning and be discharged success-
fully? (5) How can we demonstrate that the individual is improving as the result
of this treatment? and (6) Is this person ready to be discharged from treatment?
In other words: have problem-specific skills been acquired; have unwanted be-
haviors been brought under control; do the more adaptive skills respond to in-
dividual person-environment interactions (do the skills fit the environment);
and will intervention results generalize to the individual's likely place of resi-
dence? To address these questions, we summarize our early attempts at de-
institutionalization of older adults.
Our department's early efforts were aimed at geriatric units from state hos-
pitals and at local psychiatric facilities (Patterson et al., 1982). Thus, the first el-
derly clients admitted to the gerontology program at the Florida Mental Health
Institute were transferred from a state hospital. To determine what problem be-
haviors existed. each newly admitted client was assessed to identify his or her
deficits in a variety of skills which might prevent their successful placement in
community-based settings: basic and instrumental activities of daily living,
communication skills. conversation. personal information training, personal ef-
fectiveness training, self-esteem, ability to manage one's medications. and
leisure skills. Those clients not meeting the basic cutoff scores for any particu-
lar skill (e.g., personal grooming). entered a group training module. A module
was group treatment involving a set of behavioral skills to be taught. Standard-
ized manuals for staff to follow were also developed. These manuals included
a statement of objectives, brief explanation of the behavioral principles and pro-
cedures to be used, the forms and instructions for assessing the client, descrip-
tions of specific content (including materials and teaching aids), client
objectives, and forms to graph and record data.
Teaching methods consisted of lectures and the behavioral techniques of
modeling, prompting, chaining, and shaping. Clients were reassessed every
four weeks to determine whether they had improved their skills adequately to
"graduate" from the group and eventually to determine whether they were
ready to be discharged to a community-based setting, such as independent
living or an assisted-living facility. Typically, the largest change occurred
within the first four weeks of treatment. However, average length of stay was
approximately three months. Patterson and colleagues (1982) demonstrated
that one year after discharge. the majority of individuals discharged from the
Gerontology Residential Program remained in community settings, whereas
the majority of a comparison group of state hospital patients remained insti-
tutionalized.
When unusual behavior, such as hallucinations, verbal outbursts, or other
disruptive behaviors occurred but were not addressed in the modules, staff
members were instructed to observe the behavior using a behavior analysis form
(BAF) to determine what antecedents preceded the behavior and what conse-
quences might have maintained it. An interdisciplinary treatment team re-
viewed the process and collected data in order to define the problem behavior
and develop an individualized behavioral intervention to modify maladaptive
behavior and replace it with adaptive behavior. Although a primary counselor
was designated to monitor the accurate implementation of the treatment plan, all
staff were informed of each older adult's treatment plan in order to implement it
in a unified manner, ensuring uniform delivery of reinforcement, shaping, and
so on, regardless of the staff person present, where on the unit the older adult
might be, or the activity in which the client might be engaged.
PROBLEMS ENCOUNTERED IN GERIATRIC

TREATMENT PROGRAMS
Based on our experience in the aging programs at the Florida Mental

Health Institute and our attempts to disseminate these approaches to other pro-
grams and sites treating older adults, we have noted a number of areas that pre-
sent problems for successful implementation of basic behavioral approaches.
These areas include consistency of implementation of a treatment plan, gener-
alization of new skills, working with individuals with memory problems, and
working with individuals who reside in the community while attending the
treatment program.
Consistency
In the early stages of disseminating our treatment approaches and modules

to geriatric units at state hospitals, it appeared that the staff experienced a cer-
tain degree of frustration about the efficacy of behavioral approaches. With in-
vestigation, we often found that staff were not implementing the treatment plan
in a consistent manner; we asked them, "Does the unit act like a unit?" If just
one staff member or another person (e.g., family members, other clients) re-
sponds to the client in a manner inconsistent with the treatment plan, or is in-
appropriately reinforcing, that momentary lapse may inadvertently reinforce
the unwanted behavior (i.e., a partial reinforcement effect in which occasional
or intermittent reinforcement leads to behaviors that are substantially more dif-
ficult to extinguish than responses associated with consistent or continuous re-
inforcement procedurel. Inconsistency may be influenced by poor staff training,
inadequate treatment plans, or attitudes and stereotypes held by the staff. Al-
though some staff members will try hard to implement a plan as written, others
may resist because of beliefs that older adults' behaviors cannot be changed,
that the client has no potential reinforcers, or that the behavior has a biological
or physical cause.
In training geriatric staff to use behavioral techniques, we stress the need
for all staff to act in unison and reinforce (and extinguish) behaviors identically.
When this is done, behavior change is likely to occur more rapidly. This is ac-
complished by training staff in behavioral techniques including objective ob-
servation and recording of data, encouraging communication among staff in
treatment team meetings, and developing standardized assessment and treat-
ment programs. Similarly, family members and significant others should be in-
formed of (1) the benefits and consequences of adhering to the plan, and (2)
how to respond to maladaptive behavior.
Generalization of New Skills Outside the Therapeutic Environment
Patterson and Jackson (1980a, 1980b), point out that there is a significant
difference between a training environment and a therapeutic environment. The
former generates appropriate behavior that is maintained and generalized
within that specific programmatic environment; the therapeutic environment
does the same, but also results in generalization and maintenance of appropri-
ate behavior in postdischarge settings. A major concern in the application of
behavior modification is the generalization of the newly learned, adaptive be-
havior outside the therapeutic environment. A person discharged from a resi-
dential treatment program to a community placement (e.g., independent living
or assisted living facility) may not demonstrate the skills learned prior to dis-
charge unless certain predischarge intervention conditions are met.
Even with an A-B-A-B reversal design (Baseline-Treatment-Return to Base-
line-Treatment), there is a possibility that the behavior will revert to pretreat-
ment levels after the person is discharged. By planning a modified version of the
second "B" (reimplementation of treatment) condition, reversion can be avoided
by making that second condition more similar to the extratreatment environ-
ment. For example, prior to discharge, we might switch from using tokens (in a
token economy) as rewards, to the reward of more off-unit activities or weekend
visits to the new residence with participation in activities at that new site.
Treatment of Older Adults With Dementia
There are a variety of memory problems experienced by older adults. The

individual may experience benign forgetfulness in which he or she may at-
tribute memory problems to an age-related affliction. Individuals experiencing
depression may also exhibit problems or pseudodementia. Behavioral tech-
niques work well for such difficulties. However, the most challenging problems
arise in addressing problems of people with dementia. Alzheimer's disease and
related dementi as often involve a slow, degenerative process of memory, lan-
guage skills, and executive functions.
A number of basic behavioral procedures have been demonstrated to assist
older people in the early and middle stages of dementia despite declining func-
tioning. For example, Burgio and Burgio (1986) describe methods for helping
older adults control urinary incontinence, including pelvic floor exercises,
scheduled and prompted toileting, and delivery of positive reinforcement for
controlled voids. McEvoy (1990) summarizes techniques for enhancing orien-
tation, improving socialization and mood, decreasing verbal aggression, or im-
proving activities of daily living. To reduce wandering and potential risk to
one's welfare, Hussian (1982) altered the color of hallways and elevators to help
residents in one facility discriminate between hazardous areas and those areas
where ambulation would be safe. In another example, McEvoy and Patterson
(1986) describe the use of backward chaining to teach spatial orientation (Le.,
dividing the task into a series of steps, then teaching the steps in reverse order).
The staff member begins by teaching the sequence nearest to the final, desired,
behavior. When accomplished, the task is reinforced (e.g .• by praise or delivery

of tokens), and the next to last sequence is prompted by the staff member. This
proceeds until the client learns the route to the desired location.
Those people in the most severe stages of dementia are less likely to retain in-
formation or maintain skills between sessions. In such cases, the long-term goals
will be less ambitious, focusing less on independence and more on custodial care.
Community-Based Clients
Early applications of behavior modification with older adults were con-

ducted in residential facilities or with individuals spending considerable
amounts of time in day treatment or day care programs. Treatment planning for
community-residing older adults who attend treatment programs periodically
for short visits (e.g., a two-hour appointment once a week) presents greater chal-
lenges as a substantial portion of their time is spent "off-unit" and away from
the controlled environment of a residential unit. Again, consistency and gener-
alization are issues for such individuals. The primary therapist or case manager
must ensure that the family, significant others, or staff from the assisted living
facilities are brought into the treatment planning process, and that they are pro-
vided some instruction as to how to implement behavioral methodology con-
sistent with that used in the treatment program.
For community-based populations. self-management and cognitive-behav-
ioral interventions are appropriate extensions of behavior modification. In fact,
more recently, self-management and cognitive-behavioral interventions are
complementary alternatives to more traditional behavior therapies even within
residential settings.
SELF-MANAGEMENT APPROACHES
Later-life onset problems are often maladaptive responses to stress gener-

ated by the relatively rapid changes characteristic of later life. The individual's
perception that he or she can no longer predict or exert reasonable control over
the environment magnifies the stress effects of rapid change. The more an indi-
vidual expects to be in control and to cope independently with problems, the
greater the probability he or she will find a solution. Problem-solving training
may be viewed as one form of training to improve the elderly individual's con-
trol over his or her own behavior and over the environment. The relationship
between strategies for general problem solving and techniques for self-control
of specific responses has been noted by Goldfried and Davison (1976) as fol-
lows: "The major objective in problem solving is to identify the most effective
alternative, which may then be followed by other self-control operations to
stimulate and maintain performance of the selected course of action. Thus,
problem solving becomes a crucial initial phase in a more general self-control
process" (p. 187). Goldfried and Davison suggest that additional training or
therapy is often required to stimulate and maintain the behaviors necessary to
follow through on a selected course of action. Our experience confirms these
observations. While clients may generate an effective solution, they often have
trouble trying it out. Engaging in new (or renewed) adaptive coping behaviors
almost always involves increased anxiety which must be overcome if the indi-
vidual is to carry out in practice a plan he or she has endorsed cognitively.
As noted by Kanfer (1975), self-management involves the use of behavioral
techniques by the client to modify his or her own overt or covert behaviors. An
advantage of using self-management techniques is that they allow a client to
continue behavior modification outside the therapeutic environment and with-
out constant direction by the therapist. Instead of the relatively passive partici-
pant in basic behavior modification procedures, the client becomes cotherapist
by taking an active role in the identification of problems, development and im-
plementation of the treatment plan, and evaluation of progress.
Kanfer (1975) describes three major self-control components of self-manage-
ment: self-monitoring, homework and assignments, and behavior contracts. Self-
monitoring includes (1) awareness that a problem behavior is occurring and (2)
collecting data (e.g., frequency, magnitude, or intensity) about the behavior and
its consequences. For example, we have trained older alcohol abusers to maintain
a log of their urges to drink or drinking episodes (1. Dupree et ai., 1984). A review
of their logs allows the therapist to help the client avoid a relapse following a sin-
gle slip (one drink of alcohol) or to review relapse episodes to help prevent future
occurrences. Another example involved an older client in our residential pro-
gram. Despite taking antipsychotic medications, she reported hearing voices that
were disturbing to her. Staff instructed her to log the intensity, frequency, and
content of the voices she heard, as well as the antecedents to hearing the voices
(e.g., where she was, what activity she was involved in, who was present). Once
self-monitoring is accomplished, the client becomes aware of the circumstances
under which the problem behavior occurs, and is then ready to help in the de-
velopment of behavior change techniques (including self-reinforcement).
Homework or assignments by the therapist allow clients to approach their
final goals. For example, older adults in day treatment mental health programs
experiencing loneliness and social isolation might be assigned to visit a senior
center to learn what activities the program offers and to report back to the ther-
apist what was available. Another client who abuses alcohol might be asked to
call an alcoholism hotline to determine what would happen in the event he or
she experienced a slip. Such assignments can be used to diminish the stress of
placement or activities that might occur posttreatment.
A behavior contract is an agreement between the client and the therapist
or the client and a significant other (e.g., a spouse). The contract sets the
guidelines for the expected behavior and the consequences if the behavior oc-
curs (e.g., reinforcement) or does not occur. Thus, the therapist and client de-
velop and agree on behavioral guidelines for the self-management treatment
plan. The therapeutic aim is to provide the older individual with more effec-
tive coping skills specific to the antecedent conditions noted in his or her
problem behavior chain. Also, because some behaviors (e.g., abusive drink-
ing) have multiple antecedents and may change over time, the training of el-
derly clients in the analysis of problem behavior, problem solving, and
self-management skills makes them better prepared for future or evolving
high-risk situations. They are prepared to analyze, understand, problem
solve, and respond to the factors promoting unwanted behavior. Thus, inter-
vention placing greater emphasis on client analysis and self-intervention in
order to sustain positive outcome as the older person's environment contin-
ues to change enhances community stability.
COGNITIVE-BEHAVIORAL THERAPIES
Cognitive-behavior therapies (CBT) were first developed in the 1960s and

rely on the principles used in basic behavior modification and self-management
to modify thoughts and feelings. Whereas behavior modification is based on the
belief that overt reinforcement contingencies alter behavior, cognitive behavior
therapy focuses on cognitive mechanisms to alter behavior. According to Dob-
son and Block (1988), "at their core, cognitive-behavior therapies share three
fundamental propositions: 1) cognitive activity affects behavior, 2) cognitive ac-
tivity may be monitored and altered, and 3) desired behavior change may be
affected through cognitive change" (p. 4). Also, Beck (1991) notes that the psy-
chological systems of cognition, affect, and motivation are interrelated so that
changes in one system may produce changes in one or more other systems. CBT
therefore teaches one to identify and modify self-defeating thoughts and beliefs
(Dobson, 1988; Scott, Williams, & Beck, 1989).
Mahoney and Arnkoff (1978) categorized CBTs into three major divisions:
cognitive restructuring, coping-skills therapies, and problem-solving therapies.
Cognitive restructuring (CR) involves teaching the client to recognize maladap-
tive thoughts that are believed to be the antecedents to emotional problems. The
goal of cognitive restructuring "is to establish more adaptive thought patterns"
(Dobson & Block, 1988, p. 13). For example, the older client may learn to rec-
ognize his or her inaccurate thoughts or self-statements that lead to depression,
and replace them with more adaptive and accurate statements.
Older clients in coping-skills therapies may learn to use new, more adap-
tive skills when faced with stressful events or stimulation, as evident in
stress-inoculation training (Meichenbaum, 1977) and Marlatt and Gordon's
(1980,1985) Relapse Prevention (RP) model of addictive behavior. According
to the RP model, when faced with high-risk situations for drinking (e.g., neg-
ative emotional states, peer pressure, conflicts with other people), individu-
als with inadequate coping skills experience decreased self-efficacy and
increased positive expectancies about their first drink. When drinking does
occur, the slip leads to an abstinence violation effect and the self-fulfilling
prophecy that they might as well drink more since they did not maintain ab-
stinence. Programs using an RP model concentrate on teaching individuals
the skills necessary to cope with their high-risk situation or situations and
prevent a relapse. Skills are taught using didactic approaches, cognitive-
behavior therapy, modeling, behavior rehearsal, and assignments. Such ap-
proaches have been successful with regard to long-term outcome (Broskowski
& Dupree, 1981; 1. Dupree & West, 1990; Holder, Longabaugh, Miller, & Rubo-
nis, 1991; Marlatt & Gordon, 1980, 1985).
In the Department of Aging and Mental Health, we have used both self-
management and cognitive-behavioral techniques to help older alcohol abusers
overcome their problems. Clients are taught to analyze their drinking behavior
and high-risk situations into the A-B-C's described earlier. Through lecture for-
mat, behavior rehearsal, and assignments away from the program, they are
taught new coping skills (e.g., refusing a drink, managing feelings of anxiety,
tension, frustration, anger, grief, or depression; rebuilding a social support net-
work; and coping with a slip or relapse). These approaches have resulted in
successful outcomes one year posttreatment (L. Dupree et al., 1984; Schonfeld
& Dupree, 1991). Although cognitive-behavior therapy grew out of behaviorism
in its acceptance of operant and respondent components, it deviates from ear-
lier behavior therapy in its refusal to accept the tenet that environmental factors
alone determine behavior. Also, the multimodal aspect of cognitive-behavior
therapy allows a variety of methods for working with clients including system-
atic desensitization, covert modeling, mental and emotive imagery, relaxation
training, thought stopping, cognitive restructuring, biofeedback, neurolinguis-
tic programming, and cognitive modeling. Cognitive modeling combines overt
and covert strategies as the client and clinician work together to change the
beliefs and attitudes of the client about a situation. The therapist acts as a
role model, and the client acts out the same role while the therapist coaches
and monitors.
CONCLUSION
In this chapter, we have discussed a variety of behavioral interventions

used with older adults. Behavioral approaches range from very basic behavior
modification to self-management approaches and to cognitive-behavioral inter-
ventions. Problems in the use of basic behavior modification procedures arise
when procedures are administered inconsistently, when new behaviors do not
generalize to the community, when working with individuals with memory
problems, and when working with outpatient populations.
Self-management is an extension of behavior modification procedures,
with the individual learning to modify his or her own behaviors and the thera-
pist acting as a motivator and guide through the process. Cognitive-behavioral
approaches involve the modification of cognitions, normally considered events
unobservable by anyone but the client. All of the approaches (1) are based on
principles of learning, (2) use some form of behavior analysis to identify an-
tecedents and consequences of behavior, (3) target an increase in adaptive be-
haviors and a simultaneous decrease in maladaptive behaviors, and (4) often
result in an improved (context-appropriate) quality of life. Behavioral applica-
tions with older adults have been effective over a broad range of presenting
problems in diverse settings and appear to minimize many of the mispercep-
tions and inaccurate assumptions resulting from ageism, as well as the overre-
liance on the medical model to explain behavior problems. Also, by not
emphasizing intrapsychic "mysteries," and by placing less emphasis on highly
degreed therapists as the sole proprietors of knowledge relative to etiology and
change of behavior, the behavioral model permits greater participation in
change by the client. Behavior is not explained in terms of personality theory,
norms, or secondary source data. In behavioral principles, older adult behavior
is understood to be a product of environmental and organismic interactions. Be-

havior therapies have recognized and responded to the functional context of the
behavior of older adults.
Proponents ofthe behavioral perspective recognize the influence of physi-
ological change, but do not overemphasize it. They assume that maladaptive be-
havior can be remediated or ameliorated until it can be proven otherwise. This
empirical approach has been demonstrated to be successful with older popula-
tions for whom few practitioners initially held out much hope for change. Only
a few years ago, major leaders of nonbehavioral therapies were speaking of the
futility of treating adults over age 50 to 55. Behavior therapists have modified
many assumptions and can be proud of their role in developing appropriate
therapies for problems common in later life.
REFERENCES
American Psychiatric Association (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington. DC: Author.
Baltes. M. M.. & Baltes. P. B. (1977). The ecopsychological relativity and plasticity of psychological
aging: Convergent perspectives of cohort effects and operant psychology. Zeitschrift flir Ex-
perimentelle und Angewandte Psychologie, 24, 179-194.
Baltes. M. M.• & Barton, E. M. (1977). New approaches toward aging: A case for the operant model.
Educational Gerontology. 2, 383-405.
Baltes. P. B., & Willis. S. L. (1982). Plasticity and enhancement ofintellectual functioning in old age:
Penn State's Adult Development and Enrichment Project (ADEPT). In F. I. M. Craik & S. Tre-
hub (Eds.). Aging and cognitive processes (pp. 353-390). New York: Plenum.
Beck. A. T. (1991). Cognitive therapy as the integrative therapy. Journal of Psychotherapy Integra-
tion, 1,191-198.
Bernstein. L. O. (1990). A special service: Counseling the individual elderly client. Generations, 14,
35-38.
Broskowski, H .• & Dupree. L. (1981). General problem solving: An assessment and skills training
manual. Tampa: University of South Florida.
Burgio. K. L. & BurgiO. L. D. (1986). Behavior therapies for urinary incontinence in the elderly. Clin-
ical Geriatric Medicine, 2, 809-827.
Butler, R. N. (1980). Ageism: A foreword. Journal of Social Issues, 36, 8-11.
Cautela. J. R.. & Mansfield. L. (1977). A behavioral approach to geriatrics. In W. D. Gentry (Ed.). Geropsy-
chology: A model oftroining and clinical service (pp. 21-42). Cambridge. Mass.: Ballinger.
DeNelsky. G.• & Boat. B. (1986). A coping skills model of psychological diagnosis and treatment.
Professional Psychology: Research and Practice. 17, 322-330.
Dobson. K. S. (Ed.) (1988). Handbook of cognitive-behavioral therapies. New York: Guilford.
Dobson. K. S.• & Block. L. (1988). Historical and philosophical bases of the cognitive-behavioral
therapies. In K. S. Dobson (Ed.). Handbook of cognitive-behavioral therapies (pp. 3-38). New
York: Guilford.
Dupree. L. (1994). Geropsychological modular treatment: Back to the future. Journal ofGerontolog-
ical Social Work. 22. 211-220.
Dupree. L.• & West. H. (1990). Alcohol self-management in high risk situations: A group training
manual for older adults. FMHI Publication Series. 122. Tampa: University of South Florida.
Dupree. L.• Broskowski. H.• & Schonfeld. L. (1984). The Gerontology Alcohol Project: A behavioral
treatment program for elderly alcohol abusers. Gerontologist, 24, 510-516.
Dupree. L. W.• O·Sullivan. M. J.• & Patterson. R. L. (1982). Problems relating to aging: Rationale for
a behavioral approach. In R. L. Patterson. L. W. Dupree. D. A. Eberly. G. M. Jackson. M. J.
O·Sullivan. L. A. Penner. & C. D. Kelly (Eds.). Overcoming deficits of aging (pp. 7-21). New
York: Plenum.
Estes, C. L., & Binney, E. A. (1989). The biomedicalization of aging: Dangers and dilemmas. Geron-
tologist, 29, 587-596.
Gatz, M., & Pearson, C. (1988). Ageism revised and the provision of psychological services. Ameri-
can Psychologist, 43, 184-188.
Goldfried, M. R, & Davison, G. C. (1976). Clinical behavior therapy. New York: Holt, Rinehart &
Winston.
Goodstein, R K. (1980). The diagnosis and treatment of elderly patients: Some practical guidelines.
Hospital and Community Psychiatry, 31, 19-24.
Holder, H., Longabaugh, R, Miller, W. R, & Rubonis, A. V. (1991). The cost effectiveness of treat-
ment for alcoholism: A first approximation. Journal of Studies on Alcohol, 52, 517-540.
Hoyer, W. J., Mishara, B. L., & Reidel, R G. (1975). Problem behaviors as operants: Applications
with elderly individuals. Gerontologist, 15, 452-456.
Hussian, R A. (1982). Stimulus control in the modification of problematic behavior in elderly in-
stitutionalized patients. International Journal of Behavioral Geriatrics, 1, 33-46.
Kanfer, F. (1975). Self-management methods. In F. H. Kanfer & A. P. Goldstein (Eds.), Helping peo-
ple change: A textbook of methods (pp. 309-355). New York: Pergamon.
Kaszniak, A. W (1990). Psychological assessment of the aging individual. In J. E. Birren & K. W
Schaie (Eds.), Handbook of the psychology of aging (pp. 427-445). San Diego, CA: Academic.
Kimmel, A. (1988). Ageism, psychology, and public policy. American Psychologist, 45, 175-178.
Knight, B. (1986). Psychotherapy with older adults. Newbury Park, CA: Sage.
Lasoski, M. C. (1986). Reasons for low utilization of mental health services by the elderly. Clinical
Gerontologist, 5, 1-18.
Lawton, M. P. (1986). Functional assessment. In 1. Teri & P. M. Lewinsohn (Eds.). Geropsychologi-
cal Assessment and 'freatment (pp. 39-84). New York: Springer.
Lawton, M. p, Whelihan, W. M, & Belsky, J. K. (1980). Personality tests and their uses with older
adults. In J. Birren & R B. Sloane (Eds.), Handbook of mental health and aging (pp. 537-553).
Englewood Cliffs, NJ: Prentice-Hall.
Lebowitz, B. D. (1988). Correlates of success in community mental health programs for the elderly.
Hospital and Community Psychiatry, 39, 721-722.
Mahoney. M. J. (1975). The sensitive scientists in empirical humanism. American Psychologist, 30,
864-867.
Mahoney, M. J., & Arnkoff, D. B. (1978). Cognitive and self-control therapies. In S. 1. Garfield &
A. E. Berg in (Eds.), Handbook of psychotherapy and behavior change (2nd ed., pp. 689-722).
New York: Wiley.
Marlatt, G. A., & Gordon, J. R (1980). Determinants of relapse: Implications for the maintenance of
behavior change. In P. D. Davidson & S. M. Davidson (Eds.), Behavioral medicine: Changing
health lifestyles (pp. 410-452). New York: Brunner/Mazel.
Marlatt, G. A., & Gordon, J. R (1985). Relapse prevention: Maintenance strategies in the treatment
of addictive behavior. New York: Guilford.
McEvoy, C. 1. (1990). Behavioral treatment. In J. 1. Cummings & B. 1. Miller (Eds.), Alzheimer's
cisease: Treatment and long-term management (pp. 207-224). New York: Dekker.
McEvoy, C. 1., & Patterson, R (1986). Behavioral treatment of deficit skills in dementia patients
Meeks, S. (1990). Age bias in the diagnostic decision-making behavior of clinicians. Professional
Psychology: Research and Practice, 21, 279-284.
Meichenbaum, D. (1977). Cognitive behavior modification: An integrative approach. New York:
Plenum.
Miller, 1. (1979). Toward a classification of aging behaviors. Gerontologist, 19(3), 282-289.
Patterson, R L., & Dupree, L. (1994). Issues in the assessment of older adults. In M. Hersen & S. M.
Turner (Eds.), Diagnostic interviewing(2nd ed., pp. 373-397). New York: Plenum.
Patterson, R 1., & Jackson, G. M. (1980a). Behavior modification with the elderly. In M. M. Hersen,
R M. Eisler, & P. Miller (Eds.), Progress in behavior modification (Vol. 9, pp. 205-239). New
York: Academic.
Patterson, R 1., & Jackson, G. M. (1980b). Behavioral approaches to gerontology. In M. L. Michel-
son, M. Hersen, & S. M. Turner (Eds.), Future perspectives in behavior therapy (pp. 295-315).
New York: Plenum.
Patterson, R. 1., Dupree, 1. W., Eberly, D. A., Jackson, G. M., O'Sullivan, M. J., Penner, 1. A .. & Dee-
Kelly, C. (1982). Overcoming deficits of aging: A behavioral approach. New York: Plenum.
Powers, R. B., & Osborne, J. G. (1976). Fundamentals of behavior. New York: West.
Premack, D. (1962). Reversibility of the reinforcement relation. Science, 136, 235-237.
Rebok, G. W., & Hoyer, W. J. (1977). The functional context of elderly behavior. Gerontologist, 17,
27-34.
Richards, W., & Thorpe, G. (1978). Behavioral approaches to the problems of later life. In M.
Storandt, I. Siegler, & M. Elias (Eds.). The clinical psychology of aging (pp. 253-267). New
York: Plenum.
Schonfeld, L., & Dupree, 1. (1991). Antecedents of drinking for early and late-life onset elderly al-
cohol abusers. Journal of Studies on Alcohol, 52, 587-592.
Scott, J., Williams, J. M. G., & Beck, A. (1989). Cognitive therapy in clinical practice: An illustrative
casebook. London: Routledge.
Spiegler, M. D., & Guevremont, D. C. (1993). Contemporary behavior therapy. Pacific Grove, CA:
Brooks/Cole.
Wisocki, P. A. (1991). Handbook of clinical behavior therapy with the elderly client. New York:
Plenum.
CHAPTER 5
Moral and Ethical

Considerations in
Geropsychology
MICHAEL LAVIN AND BRUCE D. SALES
INTRODUCTION
Most psychologists will have acquired a working familiarity with the Ameri-
can Psychological Association's Ethical Principles of Psvchologists and Code
of Conduct (1992) (hereinafter referred to as Ethics Code or Code) in the course
of their professional education. They may know, for example, that the Code
includes an introduction, an explanatory preamble, a set of six aspirational
principles relating to competence, integrity, professional and scientific re-
sponsibility, respect for people's rights and dignity, concern for the welfare of
others, and social responsibility, and that these principles are followed by
eight sections of ethical standards by which members of the American Psy-
chological Association are bound. These standards cover general issues, test-
ing, advertising, therapy, privacy and confidentiality, teaching, research, and
publication, forensics, and resolving ethical issues. Although the aspirational
principles of the association are not binding, they can be used to help interpret
the binding standards. If psychologists who are members of the American Psy-
chological Association fail to abide by the standards, then an ethics complaint
can be brought to the association, and the association's Ethics Committee's
Rules and Procedures (1992) will govern the quasi-legal proceedings that fol-
low a complaint.
If geropsychology raises any special ethical issues, it is not because
geropsychologists operate with different ethical principles and standards than
other psychologists. Rather, it is because of the sometimes unique challenges
MICHAEL LAVIN AND BRUCE D. SALES • Department of Psychology, University of Arizona, Thcson, Ari-
zona 85721.
71
72 Michael Lavin and Bruce D. Sales
that their clients and patients present. This chapter explores issues that are
likely to loom larger for geropsychologists than for other psychologists. No pre-
tense is made that these are the only issues that are ethically or morally press-
ing for geropsychologists. Indeed, our goal is not to catalogue all issues, but to
present selected problems and apply a decision framework, in order to demon-
strate how geropsychologists can engage in ethical practice when confronted
with such challenges. Stated another way, our focus is to explore selected is-
sues in a way that will enhance geropsychologists' moral thinking, and thus
provide a basis for analyzing other problems as they arise. In order to accom-
plish our goal, we first present an analysis of the benefits and limits of ethical
codes for guiding professional behavior. Arguing that this approach is signifi-
cantly limited, we then present relevant moral principles that geropsycholo-
gists can use to improve their decision making when confronted with difficult
ethical and moral situations in practice, and apply this information to selected
problems.
Our use of the words "ethical" and "moral" requires comment. Though in
ordinary English these terms tend to be used interchangeably, we reserve the
term "ethical" for duties, prohibitions, and permissions that are given or de-
rived from the Ethics Code. The term "moral" is used to cover the deepest level
of thought that agents engage in when thinking about what they should do. A
consequence of this view is that it is conceivable that an act could be ethically
forbidden (i.e., proscribed by the Code) but morally required. The analysis of
the complex relations between the Ethics Code and morality is beyond the
scope of this chapter.
ETIDCS CODES
Benefits
There are benefits to using a profession's ethics code. First, codes set forth
minimal standards of professional conduct in a public way. Second, codes may
make collective wisdom available to other professionals. Third, codes give pub-
lic evidence as to a profession's ethics, making professionals and nonprofes-
sionals aware of the expectations. Fourth, codes often provide careful guidance
in areas that have proven to be sources of moral difficulty for a profession.
As for the first benefit, codes provide the public with a document that in-
forms all interested parties about a profession's minimal standards. Though
psychologists, for example, have a moral obligation not to exploit clients, which
exists independently of any explicit recognition in the American Psychologi-
cal Association's Code, the Code articulates this obligation in a public manner.
For example, because of the Code, psychologists may not plead that a sexual re-
lationship with a client is ethical, perhaps on the ground that the sexual rela-
tion is therapeutic.
As for the second benefit, codes are often drafted by professionals who
have made a career of thinking about issues that have proven morally difficult
for a profession. The drafters of a code bring together a collective wisdom that
is unavailable to an ordinary professional. For example, the committee devel-
Moral and Ethical Considerations in Geropsychology 73
oping or revising a code may have access to a history of troubling assessment

cases and their resolution. The average psychologist will not have had the time
to think through many of the issues connected with assessment that are explic-
itly addressed in the Ethics Code, and even more elaborately in the American
Psychological Association's Standards for Educational and Psychological Test-
ing (1985). The Code, and supplemental materials such as the Standards, there-
by offers the psychologist the benefit of thoughtful, considered guidance of
individuals respected for their ethical and legal knowledge.
Having a code also provides the third benefit of making ethical expecta-
tions public to professional and nonprofessionals alike. Even if, as part of their
professional training, all psychologists came to have the same ethical principles
and standards, the public, independent of the Code, would have no way of
knowing the specifics of those principles and standards. By making their ethi-
cal principles and standards public, organizations like the American Psycho-
logical Association make it possible for family members to reach a reasoned
conclusion about whether a geropsychologist's treatment of an elderly patient
conforms to the association's Code or to determine in advance what kind of
treatment they have a right to expect from a geropsychologist.
The final benefit of the Code is that it alerts professionals to areas that have
proven to be ethical puzzles for a profession. Therapy, testing, privacy and con-
fidentiality, forensics, research, and publication have, in the past, proven to be
areas where ethical and moral lapses are prone to occur. By reading and under-
standing their Code, psychologists can become sensitive to areas where they are
likely to encounter difficulty if they fail to proceed with suitable caution and
conformity.
Limitations
Despite the above noted benefits, codes have numerous potentiallimita-

tions. First, codes are conservative. Second, codes have a necessary limitation
in their moral authority. Third, codes are often vague. Fourth, codes often omit
mention of important topics and factors. Fifth, it is often difficult to determine
what guidance codes provide in complex cases, especially in cases where the
guidance is inconsistent (Sales and Schuman, 1993).
The conservative nature of codes is a consequence of their being political
documents. When the American Psychological Association "wrote and revised
its Ethical Principles and Code of Conduct (1992), it created a committee to pro-
duce the document. The committee, in turn, had to reach an internal consensus
on what the code should say, while simultaneously trying to produce a docu-
ment that could attain the support of the majority of American Psychological
Association members.
Given the nature of the process, no attempt is made to derive specific prin-
ciples and standards from widely accepted moral principles. At most, codes
seek to avoid manifest conflict with these principles. Professionals might there-
fore wonder how much authority the Code should have. For example, a central
feature of moral life is a respect for one's own conscience. It does not seem rea-
sonable that a code could overrule conscience, especially when the dictates of
a psychologist's conscience conform to the widely accepted moral principles.

For many psychologists, however, the decision-making process is far simpler.
The moral authority of the American Psychological Association's Code is based
in their membership in the Association, which mandates each member's com-
pliance with the Code's standards. Obviously this contractual constraint does
not apply to nonmember psychologists and non psychologists.
A third limit of ethics codes is that they tend to be vague, but for good rea-
son. First, it is often only possible to attain political agreements when a code's
provisions are vague enough to finesse disputed issues. It is easy to achieve a
consensus that individuals should respect one another, not exploit persons over
whom they have professional authority, not harass clients, and not plagiarize-
all provisions of the American Psychological Association's Ethical Principles
and Code of Conduct-but it is difficult to reach a consensus on how to opera-
tionalize these requirements. For example, at what point does a supervisor's
requests for a subordinate's services become exploitive? Second, even if psy-
chologists are conscientious in observing or trying to observe the Code, it may
be difficult to document this empirically. Psychologists making a sincere at-
tempt to avoid objectionable multiple relationships, as required by the Ameri-
can Psychological Association's Code, may have great difficulty determining
when they have entered into an objectionable multiple role. No amount of scru-
tinizing of the Code will necessarily resolve the issue for them. For example, us-
ing the services of a patient to resolve a plumbing problem may be necessary for
the psychologist in a rural community. Moreover, this multiple relationship
may be neither exploitive nor harmful to the patient.
Because codes do not attempt to replace legal codes. they are never com-
prehensive. Moreover. to be of use to the average professional. codes must be
of manageable length. These two facts about codes guarantee that codes will
omit important topics. Geropsychologists turning to the American Psycholog-
ical Association's Code may well discover that matters of pressing concern to
them are not addressed. For example. although a geropsychologist might very
much like to have clear advice on what informed consent should consist of.
and how it should be administered. ethics codes do not prOVide the needed
information.
Finally. even if a code provides clear advice. professionals might wonder
whether it is consistent with other provisions of the relevant code. For exam-
ple. a geropsychologist might well believe that he has a code-given obligation
to honor a commitment of confidentiality made to a patient. yet also have an-
other code-given obligation to surrender the otherwise confidential client
records to the managed care entity that is paying for services. For example.
consider the situation where the elderly patient's employer has a contract
with the managed care entity rerquiring it to provide the employer with ac-
cess to all employee patient records as a condition of continuing the contract.
Even if the geropsychologist informs the patient of this limitation in confi-
dentiality, he might not have informed the patient of all potential risks of di-
vulging personal information. One example of such risk is the employer firing
the employee based on information contained in the geropsychological
records.
MORAL THINKING
Moral thinking has at least three salient characteristics (Rachels, 1993). It is

universal; it is impartial; it is reason driven. By universality, we mean that
moral claims are not local. It would be odd to claim that cheating your clients
is morally permissible, if only you have the good fortune to live in the right
place or right time. Also, it would be morally unacceptable to acquiesce to the
wish of an elderly client's son to place his cantankerous, aging parent in a resi-
dential facility, when the neuropsychological assessment suggests that the par-
ent is fully capable of living independently. To sell one's services in such a way
is partial and immoral. Finally, when we make moral claims, we have an obli-
gation to defend the claims with reason. Unlike personal preferences (e.g., pref-
erence for one flavored tea over another), moral judgments require reasons to be
morally defensible.
These three characteristic features of moral thinking do not answer substan-
tive moral problems. To do that, one also needs the help of moral principles. De-
ciding what moral principles should regulate the behavior of psychologists is a
controversial matter. Nevertheless, several principles have attained prominence
in recent years, especially in medical ethics writing (Beauchamp & Childress,
1994; National Commission for the Protection of Human Subjects of Biomedical
and Behavioral Research, 1978; President's Commission for the Study of Ethical
Problems in Medicine and Biomedical and Behavioral Research, 1981, 1983). In
particular, Beauchamp and Childress (1994) have been influential in articulating
four principles that have gained wide allegiance: autonomy, beneficence, non-
maleficence, and justice. To this we add a fifth principle: fidelity to one's pro-
fession and client. Though the formulation, ultimate justification, and logical
relationships of these five principles are certainly controversial, their relevance
to moral and ethical decision making is accepted by most psychologists.
Specifically, few, if any, psychologists would assert that it is morally irrel-
evant whether a decision limits a person's autonomy or self-determination.
Few, if any, psychologists would claim that a client's well-being is irrelevant in
deciding what to do. Few, if any, psychologists would claim that whether a
client is harmed is irrelevant to their deciding what to do. Few, if any, psychol-
ogists would think issues of justice are irrelevant to moral and ethical decision
making. And, finally, few, if any, psychologists would argue that they should
not be faithful to the ideals and goals of their standards and to meeting the clin-
ical needs of their clients.
Many psychologists might have other principles and moral or religious
ideals that help them to reach morally sound decisions, but these five principles
seem to capture features that the overwhelming majority of psychologists would
be willing to acknowiedge. They might well represent a minimum consensus on
principles that should guide psychologists in their moral decision making and
the American Psychological Association in formulating its ethical principles and
standards of conduct. At a minimum, ethical principles and standards that con-
flict with any of these moral principles should require justification. For example,
it might be that regulating the sexual conduct between competent clients and
therapists, as the American Psychological Association's standards do, infringes
on the principle of autonomy, but is nevertheless justified, since such restriction

can prevent egregious violations of the principle of nonmaleficence.
Psychologists with a sound understanding of these five moral principles
are well positioned to appraise the American Psychological Association's Ethi-
cal Principles and Code of Conduct and to effectively respond to many issues
that are not covered by the Code.
THE SPECIAL CONCERNS

OF GEROPSYCHOLOGY
Let us now apply these lessons to a sample of geropsychological problems.

Though what follows is not exhaustive, it will provide the necessary introduc-
tion to the approach that geropsychologists should assume when faced with
challenging situations.
Decisional Capacity and Disease

It is a familiar idea that by the time people have entered their 60s, they no
longer think as fast as they once did. A healthy person taking an intelligence
test at age 65 would be expected to attain approximately the same scale score he
attained as a young man but his raw score will have declined. One will need
fewer right answers to have an IQ of 130 at 65 than one needed to obtain the
same score at 35. A good reason for this is a general slowing. Most people will
not be as nimble maneuvering blocks at 65 as they were at 35.
This kind of slowing is not particularly threatening to the judgment re-
garding whether a person has the capacity to make ordinary decisions. The
geropsychologist will not usually view the ordinary slowing of processing or
the ordinary decline of raw scores with age as symptomatic of decisional inca-
pacity. At most, the geropsychologist may take an interest in devising tech-
niques to make efficient thinking easier for the elderly. But there are other kinds
of decline, vastly more severe than ordinary slowing, that will draw the atten-
tion of the geropsychologist.
For example, Alzheimer's disease begins to appear in the population in sig-
nificant percentages during the seventh decade of life (Bachman et al., 1993;
Evans et a1., 1989; Henderson & Hasegawa, 1992; Kolb & Whishaw, 1995). At 65,
about one adult in 20 would be showing the debilitating effects of Alzheimer's
disease. By age 70, the number of those fighting the disease rises to one in 10,
and by age 80, between 40% and 50% of the population would exhibit some
form of dementia, even if not related to Alzheimer's disease.
The clinical picture of increasing diagnosable dementing disease with in-
creased age poses a challenge to geropsychologists seeking to reach morally
and ethically defensible decisions about the decisional capacity of the elderly.
The first and obvious challenge is that presence of a dementing disease is not,
on its own, sufficient to show a lack of decisional capacity. A person's capac-
ity to make a decision depends on the kind of decision required (Buchanan &
Brock, 1989; Drane, 1985). Many simple, low-risk choices require very little
decisional capacity, whereas more complicated, riskier choices may require

substantial decisional capacity. Consequently, a person in the early stages of
Alzheimer's disease may have the capacity to write a living will or create a
durable power of attorney for medical purposes that he would not have at a
later stage of the disease.
Since presence of a dementing illness does not of itself establish a person's
decisional capacity, the geropsychologist must have a clear conceptualization
of what functional capacities a person needs to make competent decisions.
Buchanan and Brock (1989) have made an important contribution to this point.
Their analysis shows that decisional capacity requires that a person be able to
understand and deliberate with reference to his own values. Further, under-
standing and deliberation are continuous variables; nobody understands any-
thing perfectly, while deliberation is something that people do with varying
degrees of skill. Individuals even vary in the degree to which they know, can ar-
ticulate, and can recognize their own values in deliberative choice. The impor-
tance of these capacities for competent decision making is intuitively obvious.
When individuals do not understand the question before them, they cannot de-
cide it well, unless lucky. If individuals cannot deliberate, they cannot use what
they understand, even if they can understand a question and the information
relevant to making a choice about it. And if individuals do not know their own
values or if they use values alien to them, they cannot make a choice that re-
flects their personal beliefs and goals.
Geropsychologists assessing whether an Alzheimer's patient has the deci-
sional capacity to make particular kinds of choices, for example, whether to re-
main at home or move to a nursing home, whether to accept a life-saving
surgery or to reject it, must also recognize that the degree of capacity needed to
make competent choices will depend on the kinds of question at hand. A grand-
mother may have the ability to make a decision about whether to make a small
gift to a grandchild, but lack the ability to assess the risks and benefits of a med-
ical procedure in relationship to her own goals.
Sometimes clinicians will believe that if a patient is competent to decide to
accept a procedure, then he must also be competent to reject it. This is a mis-
taken belief. For example, accepting a low-risk procedure that will save a per-
son's life requires far less decisional capacity than the rejection of it might.
Indeed, rejecting a procedure may require that the person understand the full
range of high-risk consequences that follow and also know how to assess these
consequences in relation to his conception of his own good. Moreover, given
that there is normally a presumption that people are competent, there will typ-
ically be no reason to question low-risk choices, but many reasons to assess a
person's capacity to make a risky choice. It is not being argued that individuals,
even mildly demented individuals, should never be allowed to make a risky
choice. They may well have the capacity to make the choice. Rather, it is being
argued that a risky choice may serve to trigger inquiries that a nonrisky choice
would not.
Using a moral and ethical analysis helps us clarify the issue. In the absence
of a countervailing moral consideration, the principle of autonomy commands
that a person's self-determination be respected. It is only when a person appears
to have made a decision that runs counter to ordinary expectations that one has
grounds for assessing his competence to make a choice of that kind, and the
principles of nonmaleficence and beneficence support such questioning. There-
fore, although all Alzheimer's patients will eventually lose the capacity to make
risky choices of any complexity, geropsychologists need to keep in mind that
moral (and ethical) principles require careful professional judgment about
when to conduct a competency evaluation, and how often such an evaluation
needs to be considered.
As Alzheimer's disease progresses, patients progressively lose more of the
functional capacities that enable them to make competent choices. At some
point, a geropsychologist, after a reevaluation of the patient, might judge that
the person is no longer competent, perhaps recommending to family members
that they seek guardianship over that patient. This is not an easy decision,
since once declared incompetent, patients may lose control over many aspects
of their life. For example, they may lose the ability to decide where to live and
how to spend their money. Given the severe compromise of a person's self-
determination, if declared incompetent, only the principle of nonmaleficence
should underwrite this infringement on the principle of autonomy. The mere
observation that a person might do better in a different setting, and concomi-
tant desire to help that person, is not enough to justify so severe a reduction
in self-determination. Indeed, severe reduction of autonomy results in harm,
despite the geropsychologist's best intentions. Thus, there must be some rea-
soned expectation that the person declared incompetent is being spared a ma-
jor harm.
Given the gravity of an incompetency determination, it should not be sur-
prising that it might place the geropsychologist at odds with a patient's family.
One source of ethical and moral difficulty in incompetency determination can
be ambiguity about whether the client in assessments of decisional capacity is
the person being assessed or the family members seeking (and perhaps paying
for) that assessment. For example, children may wish an elderly father assessed
as being incapable of managing his own affairs. The children may have diffi-
culty understanding the geropsychologist's obligation to clarify his role in rela-
tion to the children and the father. The American Psychological Association's
Ethics Code and the moral principle of fidelity to one's profession and clients,
require that all parties understand the nature of the geropsychologist's relation-
ship to each ofthem.
Matters can become even more difficult if the family proposes actions that
the geropsychologist believes will worsen the elderly client's conditIon. For ex-
ample, people with Alzheimer's disease, even at early stages, have diminished
spatial memory (Lezak, 1995). Consequently, although they can find their way
about in a familiar environment, they have enormous difficulty or even find it im-
possible to find their way about in a novel environment. A nursing home place-
ment can have a devastating impact on a person with an impairment of spatial
memory. And even if the children are made the guardians of the elderly person,
at least in theory they have an obligation to decide in their charge's best interest
(Buchanan & Brock, 1989), though this duty has been disputed (Hardwig, 1990;
Nelson & Nelson, 1995). Geropsychologists have an expert knowledge of the
needs of elderly clients. Moreover, geropsychologists understand how different
responses of family members to their elderly person's mental disorders can affect
how rapidly and severely a disorder unfolds. Given a geropsychologist's special

knowledge, he may have good reasons for questioning whether an elderly client's
children are, in their capacity as guardians, deciding on the basis of what is best
for their impaired elderly parent. These guardians may be reaching an expedient
solution that is most convenient for them. Nevertheless, although respect for
moral principles requires that geropsychologists be vigilant about clear violations
of the patient's interests, geropsychologists must remember that a client's best in-
terest is not a determination made by psychologists. Rather, it is a determination
that the courts will make, and one that courts are less likely to need to make if
geropsychologists remain cognizant of the limits of their competence. To act oth-
erwise assumes a competency that geropsychologists do not possess in virtue of
their specialist training, and violates the moral principle of fidelity.
Assessment Issues
The issues raised in connection with Alzheimer's disease and decisional
capacity make reference to assessment. Both ordinary morality and the Ameri-
can Psychological Association's ethics code require that clients be tested ap-
propriately. Ordinary moral thinking forbids imposition of significant harm,
and unreliable tests, and testing can threaten a person with such serious conse-
quences as misdiagnosis and loss of liberty. Unfortunately, it is often difficult
for geropsychologists to determine whether they are meeting this obligation to
use appropriate tests.
The situation is acute in the case of the oldest patients. For the age group
over 80, few tests have been adequately normed. When such well-known scales
as Wechsler's intelligence and memory scales were first normed, insufficient
numbers of people lived long enough to justify the expense of establishing
norms for the oldest age group. Matters have changed as improved medical and
public health measures have resulted in a rapidly growing elderly population.
The nature of this population poses serious moral questions of justice for
geropsychologists. One way of understanding testing is to conceive of it as ac-
tion-guiding. A person's test results enable psychologists to diagnose, identify
strengths and weaknesses, and establish a coherent treatment plan. However,
interpretation of test results is dependent on the norms for the relevant test. As
for the moral principle of justice, establishment of norms forces geropsycholo-
gist to consider, among many other factors, the moral consequences of adopting
one population sample as normative, rather than another.
Since distributive justice concerns who gets what and on what basis, the
testing decisions of geropsychologists serve as information backdrops for mak-
ing decisions about entitlements of the elderly. A decision to include a rela-
tively large number of impaired people in developing norms could result in a
belief that diminished abilities are a normal consequence of aging, whereas a
decision to develop norms from a sample that excludes people with conditions
that often accompany aging could result in stigmatizing many older people. No
position on the development of norms is likely to be without difficulties; per-
haps the best solution is to opt for multiple norms. For example, in relation to
expectations, prospective research on the elderly might wish to employ norms
based on how disease-free older adults test. Such a conception of norms would
make it possible to encourage the development of lifestyles that maximize
health and vigor among the elderly. At the same time, these norms may be un-
realistic for a significant percentage of elderly persons. Thus, it may well be
appropriate to have a second set of norms that recognizes the elderly popula-
tion as it is now constituted. Consequently people who might look debilitated
or mildly debilitated against a high standard are not labeled as debilitated on a
less exacting conception of the appropriate norm. This proposal is not without
difficulties of its own. In particular, the assignment of entitlements often flows
from a significant deviation from the relevant norm. A decision to use a lower-
normed group could have the effect of leaving fewer people entitled to special
services. Balanced against that effect is cost savings. Society now makes sig-
nificant contributions to the elderly (Daniels. 1988). Employment of a high
norm could result in the diversion of resources to the elderly from some other
group. Space limitations preclude us from pursuing this issue further in this
chapter. Our goal here is simply to make geropsychologists aware that the set-
ting of norms, a seemingly innocuous technical exercise, is something that has
consequential moral dimensions that should be considered in professional de-
cision making.
In addition to issues of justice, testing also raises moral and ethical issues
as to how to test. Psychological testing can be time consuming and demand-
ing on the resources of the testee (Anastasi, 1988). For example, certain ap-
proaches to testing raise an often unnoticed problem. In the interest of saving
time or because they are committed to an actuarial approach to test interpreta-
tion, some psychologists rely on test batteries. At the extreme, some psycholo-
gists have a psychological examiner perform an invariant pattern of tests and
interpret the results.
The present state of knowiedge makes this battery approach to testing older
clients morally and ethically suspect (Lezak, 1995). It can be demoralizing for
a patient to attempt to answer numerous questions beyond their capacity or to
continue in an examination after a psychologist has noticed that the informa-
tion sought has already been obtained. By administering their own examina-
tions or at least restricting administration of examinations to those who have
the training necessary to know when a portion of a battery has ceased to con-
tribute incremental validity to a battery, psychologists spare their patients need-
less testing burdens.
This objection to the unrestrained use of test batteries is rooted in the
principle of nonmaleficence. However, one crucial empirical claim underlies
it. If the use of a battery does indeed contribute significant incremental valid-
ity to an assessment, then there is no objection to its use. The onus, though, is
on the psychologist who claims that only subjecting a stressed patient to a full
battery will provide the information needed for a good assessment. The cur-
rent state of knowledge does not make that an easy claim. Moreover, to the ex-
tent that a patient is not distressed or is enjoying an assessment, the moral
argument against invariant administration of batteries is undermined. Again,
the point is not to settle the issue, but to remind geropsychologists that many
clients, especially demented elderly clients, require respectful treatment in
their assessment.
Suicide
Suicide poses more questions to the geropsychologist than to psychologists

working with younger populations. Young people rarely have compelling rea-
sons for killing themselves. Among the young, psychologists assume and have
reason to assume that suicidality is a state that arose from a crisis and will pass
in short order. Older persons are far more likely to have good reasons for wish-
ing to die or wishing to enlist somebody else's aid in dying. Progressive diseases
such as Alzheimer's disease, horrifically painful, killing diseases such as bone
cancer, and many other conditions can place an older person in a position in
which, at least arguably, it is rational to want to die or to kill oneself.
And yet there is a long, venerable tradition in the caregiving professions
that opposes both suicide and what is often called "active euthanasia." Physi-
cians often support the maxim, "Thou shall not kill, but need not strive too of-
ficiously to keep alive"(American Geriatrics Society, 1991; American Medical
Association, 1992). Consequently, it is often allowed that there is an important
difference between killing a patient (active euthanasia) and letting a patient die
(passive euthanasia). Common medical practice holds that it is permissible, if
patients consent, to let them die, but not permissible, even with their consent,
to kill them. Geropsychologists seeking to assess an elderly person's ability to
reach a reasoned decision to end his own life or to refuse to accept potentially
lifesaving interventions, need to have an understanding of the moral thinking
that has shaped his reasoning about these end-of-life decisions. Even though
geropsychologists themselves will not perform the acts that lead to the end of a
patient's life, they need to understand the moral terrain, if they are to think co-
herently about life-ending decisions in elderly persons.
A person with a painful, killing disease or a progressive dementing illness
may have great difficulty in understanding the refusal of many caregivers to as-
sist them in ending their life. Ordinary thinking that suicide or the refusal of
lifesaving treatment is an evil may be evaluated differently when someone is
faced with a set of facts that confront many elderly persons. Unlike a young per-
son, whose depression or disease will often succumb to treatment, elderly peo-
ple face a grimmer set of realities. In some cases they are going to die, and the
chief question is when or how. In other cases, even though death is not immi-
nent, the elderly person faces disintegration of himself as a dementing illness
destroys ever larger portions of his brain. Few young people encounter the
numbing realities of the older person who is dying a painful death or who has a
dementing disease. Moreover, older persons have had a life's experience to en-
able them to have a clearer recognition of what their lives mean and the cir-
cumstances under which they wish to continue to live. No two people need
reach the same conclusion when confronted with the same facts. For some el-
derly persons, the suffering that accompanies death or disease has a religious
significance that perhaps enables them to bear what awaits them. Other elderly
persons have beliefs that assign no positive value to pain or loss of capacity. For
them, the prospect of an existence in a demented state or in constant pain may
be judged as a complete evil. They may not wish to continue to live in such cir-
cumstances. The geropsychologist, in the process of exploring a desperately ill
elderly person's sense of life, will learn much about the nature of the person.
The geropsychologist, if mindful of a person's right to self-determination, will

recognize that in some instances, the view that it is a good thing to try to keep a
person living may not be appropriate and that to continue living can even be in-
sulting to that person.
Suppose that an elderly man has a painful bone cancer, less than three
months to live, and does not wish to wait for death to arrive naturally. If a
geropsychologist's assessment of him leads to the conclusion that he is compe-
tent to make a decision to end his life, should the geropsychologist declare him
incompetent solely to stop the patient from seeking the means to achieve his
goal? This situation is both real and disturbing because the elderly person can
receive as much medication as is necessary to keep him completely free of pain.
The dying man may have no wish to die in an analgesic stupor. He may have a
different preference. It is stretching credibility to argue that drugging the person
to an insensate state benefits him. If he is insensate, he is obviously not bene-
fiting. Nor is it plausible to claim that the duty of nonmaleficence requires that
he be encouraged to drug himself rather than kill himself. Again, in his own,
competent judgment, he has reached a conclusion that his life is no longer a
good to him. The clinician has no psychological basis to overrule him.
In a seminal article, Rachels (1975) has gone further and argued that there
is an absence of a morally significant difference between letting die and killing,
thereby suggesting that if clinicians may withdraw life-sustaining procedures,
they may also actively do what ends life, with the patient's permission.
Rachels's argument for the absence of a difference ran as follows: Suppose a
man wished to kill a child to gain insurance money. He enters a bathroom while
the child is bathing, then drowns the child. In that case, he has intentionally
killed. In case two, the man again enters the room. As he does so, the child
slides under the water. The man is, prepared to kill the child if need be, but in-
stead the child dies without his assistance. He lets the child die. According to
Rachels, there is no difference between the two acts, morally speaking. He is a
monster in either case. If one act were morally worse than another, the first
story would result in a more severe judgment than the second. Undoubtedly,
killing usually occurs in circumstances that make it worse than letting die;
however, it is the attendant circumstances, not the fact that somebody killed
rather than let die, that makes the moral difference.
Geropsychologists thinking about this issue need to understand that Ra-
chels's argument overlooks certain clinical realities facing elderly clients. In-
deed, these clients also may not understand such clinical realities at the time of
being assessed by the geropsychologist. Geropsychologists need to be able to ex-
plain them. Steinbock (1979) makes the case well. Competent dying and de-
menting clients need to understand their true situation, so that they can make
a rational choice. For example, a competent patient has a moral right and a
legally recognized right to refuse treatment, even though refusal of ordinary
care will sometimes hasten a person's death. Moreover, although physicians
have a duty to provide ordinary care to competent and incompetent patients,
they have no duty to provide extraordinary care. Although failing to provide
care, in either instance, may hasten a patient's death, in the case of extraordi-
nary treatment, benefits of treatment may be sufficiently speculative so that
there is no duty to provide it. Patients need to understand that while the prin-
ciple of autonomy supports their right to refuse lifesaving treatment, the same
principle does not entitle them to insist that others do anything for them. If it
did, autonomy would include not only a right to self-determination but also a
right to "other" determination. Thus, respecting a person's self-determination
does not yield a right to be killed intentionally. Clinicians who respect a pa-
tient's treatment refusal, or who do not provide extraordinary care, are not in-
tentionally killing him. They are working within the traditional value system of
medical practice.
Geropsychologists who understand the argument between Rachels (1975)
and Steinbock (1979) can at least bring their clients to an understanding of the
current situation, where physicians normally resist arguments to intentionally
end a desperately ill person's life. Once geropsychologists grasp these argu-
ments, they face a difficult choice of their own. They must grapple with their
own moral beliefs and what these beliefs imply about what stance they should
take toward elderly clients who wish to end their life on their own or to have
the assistance of others in ending it.
In the former situation, if the patient is fully competent to reach the decision,
the moral principle of autonomy requires that the geropsychologist report those
results to the client (e.g., the family) and not try to achieve an alternative result
that satisfies the geropsychologist's or client's wishes. In the latter situation, if the
person is competent, the geropsychologist may inform the person qua client that
in the current state of law, persons may ask for others to stop doing things that are
keeping them alive. The client should also be made to understand that it may be
illegal for his caregivers to intentionally bring about his death. Further, the
geropsychologist is morally obligated to report the conclusion of competency,
even though a determination of incompetency could result in the person's life be-
ing saved via the continued administration of ordinary care. The duty of geropsy-
chologists is to give thorough and honest assessments to elderly clients, even with
grim diagnoses. Being old does not inoculate clients against depression and other
reactions to their illnesses that could render them incompetent to make decisions
about their care, but geropsychologists must remain alert to the possibility that a
desire to die is not rooted in a transient psychological problem.
Finding Meaning in One's Life
If thinking about the reasons that older people may wish to die is the
night of geropsychology, helping older people see meaning in their lives is the
day. Although older people suffer many of the problems that younger people
do-depression, sexual dysfunction, anxiety, and the like-important differ-
ences mark the two populations. The younger person is often able to achieve
a meaningful life in face of psychological obstacles. A young woman with a
social phobia confronts serious impediments to leading a meaningful life. The
older person seeking psychotherapy for the first time perhaps comes with a
different perspective and different problems. Older clients are likely to have
a vivid sense of their mortality. They often have seen loved ones die. They
have seen their own physical capacities decline. They may need reassurance
about the extent to which the physical and psychological changes that they
are undergoing are normal. They also may be seeking a way of seeing meaning
in the life they have lived and in learning ways to spend well what time they
have left.
Geropsychologists should keep in mind that this is not simply the deliv-
ery of a technology, as is the case if one is teaching an elderly person effective
techniques for combating insomnia, depression, bereavement, or anxiety. Clin-
ical geropsychologists are being conscripted in an attempt to help the elderly
client see meaningful patterns. When geropsychologists lack a coherent phi-
losophy of life of their own, they are going to be at a loss as to how to help such
clients. But there are good reasons for questioning whether, even when
geropsychologists have a coherent philosophy of life, they should offer it as
part of their services as psychologists. Indeed, the task is to help the older per-
son see what has been good, what has been bad, and how it all has come to-
gether to give them a life that means something. Since these are questions of
values, geropsychologists need to seriously consider the possibility that nei-
ther their training nor acquired expertise positions them to help the older per-
son in his quest for meaning. What the geropsychologist can do is to try to
cultivate a list of contacts that may enable meaning-seeking older people to ob-
tain the assistance they need. In some cases, they may be encouraged to dis-
cuss their life with loved ones or a spiritual adviser. Until geropsychologists
have reason to believe that they have expertise in helping people find mean-
ing, they would do well to resist the temptation to assume the mantle of com-
petence regarding what makes a life meaningful.
In addition to the moral argument just given against geropsychologists
helping elderly clients in their meaning quests, the American Psychological As-
sociation's Ethics Code lends support to this restriction on geropsychological
practice. The Code enjoins psychologists not to practice beyond their compe-
tence. Since there is reason to be skeptical that psychologists have expertise in
identifying what makes a life meaningful, geropsychologists should proceed
with extreme caution in assisting elderly people in the quest for meaning in
their lives. It may be appropriate to help with the finding of narrative themes
and the like, but the question of meaning itself is not one that a geropsycholo-
gist is well trained to answer. This is not an admonition for insensitivity to the
needs of meaning-seeking elderly people, but a call for humility and recogni-
tion of the limits of one's true competence as a geropsychologist. The challenge
to geropsychologists who would offer guidance in an area that has traditionally
been the province of religion is to give some reasoned ground for supposing
that, in offering guidance in this area, they are still working as psychologists. In-
deed, this requirement is supported by the moral principles of beneficence,
nonmaleficence and fidelity to one's profession and patient.
SUMMARY
We have argued that geropsychology does not call for a different set of
moral or ethical principles. What is distinctive about moral and ethical rea-
soning in geropsychology is the problems that are confronted. In particular,
the age of geropsychologists' clients makes it likely that geropsychologists
will encounter certain kinds of moral and ethical problems more frequently
than other psychologists. We have sampled but a few of these problems. The
aim of a limited sampling was to set out a context for moral and ethical rea-
soning about difficult problems. By engaging in such reasoning, geropsychol-
ogists place themselves in a position to achieve an intradisciplinary, and
ultimately extradisciplinary, consensus about what should be done in certain
kinds of circumstances. Our approach does not assume that the principles of
autonomy, beneficence, nonmaleficence. justice, or fidelity will themselves
survive the dialectical process unchanged or even survive at all. The purpose
of moral and ethical inquiry is to evolve deeper moral and ethical under-
standing, not to embalm it at some instant in time. Other areas have yielded
to consensus using similar procedures. There is no reason to believe that the
problems now confronted by geropsychologists cannot also attain solutions
by consensus.
REFERENCES
American Geriatrics Society, Public Policy Committee. (1991). Voluntary active euthanasia. Journal
of the American Geriatrics Society, 39, 826.
American Medical Association, Council on Ethical and Judicial Affairs. (1992). Decisions near the
end of life. Journal of the American Medical Association, 267, 2229-2233.
American Psychological Association. (1985). Standards for educational and psychological testing.
Washington, DC: American Psychological Association.
American Psychological Association. (1992). Ethical principles of psychologists and code of con-
duct. American Psychologist, 47, 1597-1611.
Anastasi, A. (1988). Psychological testing (6th ed.). New York: Macmillan.
Bachman, D. 1., Wolf, P. A., Linn, R T.. Knoefel. J. E., Cobb, J. 1., Belanger, A. J., White, L. R, &
D' Agostino, R B. (1993). Incidence of dementia and probable Alzheimer's disease in the gen-
eral population: The Framingham Study. Neurology, 43, 515-519.
Beauchamp, T. 1., & Childress, J. F. (1994). Principles of biomedical ethics (4th ed.). New York: Ox-
Buchanan, A. E., & Brock, D. W. (1989). Deciding for others: The ethics of surrogate decision mak-
ing. New York: Cambridge University Press.
Daniels, N. (1988). Am I my parents' keeper? New York: Oxford University Press.
Drane, J. (1985). The many faces of competency. Hastings Center Report, 15, 17-21.
Ethics Committee of the American Psychological Association. (1992). Rules and procedures. Amer-
ican Psychologist, 47, 1612-1628.
Evans, D. A., Funkenstein, H., Albert, M. S., Scherr, P. A., Cook, N. R, Chown, M. J., Hebert, L.
E., Hennekens. C. H., & Taylor. J. O. (1989). Prevalence of Alzheimer's disease in a com-
munity population of older persons. Journal of the American Medical Association, 262,
2551-2556.
Hardwig, J. (1990). What about the family? Hastings Center Report, 20, 5-10.
Henderson, A. S., & Hasegawa, K. (1992). The epidemology of dementia and depression in later life.
In M. Bergener (Ed.), Aging and mental disorders: International perspectives. New York:
Springer.
Kolb, B., & Whishaw, 1. Q. (1995). Fundamentals of human neuropsychology (4th ed.). New York:
W. H. Freeman.
Lezak, M. D. (1995). Neuropsychological assessment (3rd. ed.). New York: Oxford University Press.
National Commission for the Protection of Human Subjects in Biomedical and Behavioral Re-
search. (1978). The Belmont report (DHEW Publication No. 0578-0012). Washington, DC:
Author.
Nelson, H. 1., & Nelson, J. L. (1995). The patient in the family: an ethics of medicine and families.
New York: Routledge.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behav-
ioral Research. (1981). Protecting human subjects. Washington, DC: U.S. Government Printing
Office.
President's Commission for the Study of Ethical Problems in Medicine and Biomedical and Behav-
ioral Research. (1983). Implementing human research regulations. Washington, DC: U.S. Gov-
ernment Printing Office.
Rachels, J. (1975). Active and passive euthanasia. New England Journal of Medicine, 292, 75-80.
Rachels, J. (1993). The elements of moral philosophy (2nd ed.). New York: McGraw-Hill.
Sales, B. D., & Shuman, D. (1993). Reclaiming the integrity of science in expert witnessing. Ethics
and Behavior, 3, 223-229.
Steinback, B. (1979). The intentional termination of life. Ethics in Science and Medicine, 6, 59-64.
CHAPTER 6
Normal Memory Aging

KATIE E. CHERRY AND ANDERSON D. SMITH
INTRODUCTION
Elderly people often comment that their memory is not as good as it used to
be. Complaints of memory loss vary widely among older adults. Some express
little concern over age-related declines in memory, but others show greater
worry and concern. Older adults' concerns are understandable in light of the
increased public awareness of memory impairment associated with Alz-
heimer's disease (Reisberg, Ferris, deLeon, Crook, & Haynes, 1987). Nonethe-
less, self-reported memory problems do not necessarily provide an accurate
indication of older persons' performance on laboratory-based measures of
memory (Dixon, 1989).
For practicing clinicians, memory concerns raise multiple interpretive is-
sues. A variety of factors, including emotional and physiological states, may
contribute to memory problems in older persons. For instance, undue memory
complaint may be symptomatic of clinical depression, whereas gross perfor-
mance deficits on standardized memory measures may signal a serious health
condition. Accurate identification of the source of memory deficits in older
adults has important implications for treatment and prognosis. Thus, under-
standing the developmental course of memory abilities in adulthood and the
implications of these changes for older persons' daily lives is important for clin-
ical geropsychologists.
This chapter is organized as follows: In the first section, we distinguish
between normal memory aging due to maturational processes and patholog-
ical memory aging that may be attributable to disease states or other factors. In
the second section, we offer five general conclusions about normal memory
functioning in adulthood based on a selective review of experimental studies of
memory aging. In the third section, we explore memory intervention techniques
KATIE E. CHERRY • Department of Psychology, Louisiana State University, Baton Rouge, Louisiana
70803-5501. ANDERSON D. SMITH • School of Psychology, Georgia Institute of Technology, At-
lanta, Georgia 30332-0001.
87
88 Katie E. Cherry and Anderson D. Smith
and evaluate the efficacy of these methods with older persons. In the fourth sec-
tion, we consider broad implications of experimental findings on memory aging
for clinical practice.
NORMAL VERSUS PATHOLOGICAL

MEMORY AGING
Normal Memory Aging

Scope and Definition
Persons of all ages experience memory failures that may be attributable to
internal states (e.g., inattention, interference, fatigue), external factors (e.g., in-
adequate retrieval cues, information overload), or a combination. Forgetfulness
in daily life occurs more often for older than younger adults, as revealed in sur-
vey and questionnaire studies of memory (Cavanaugh, Grady, & Perlmutter,
1983; Gilewski & Zelinski, 1986). Laboratory studies of memory in healthy
older adults also provide substantial evidence of age-related deficits in both im-
mediate and long-term retention (see Craik & Jennings, 1992: Kausler, 1994;
Smith, 1996; Smith & Earles, 1996, for reviews).
Behaviors such as forgetting names, dates, or where the car keys were
placed are characteristic of normal memory aging (Jarvik, 1980). Ample ex-
perimental evidence supports this view. Researchers have attempted to
model everyday memory behaviors using laboratory-based procedures that
permit strict control over subject characteristics, task demands, and other
potentially confounding factors (West, 1989). The patterns of age-related
deficits in memory for everyday materials (e.g., names and faces, prose, tele-
vision programs) are generally similar to those observed on traditionallabo-
ratory memory measures (see Backman, Mantila, & Herlitz, 1990; Salthouse,
1991, for reviews).
Descriptive Terms
Several descriptive terms have emerged in recent years to characterize de-
clining memory abilities in older adults who show no signs of depression or de-
mentia. For example, the National Institute of Mental Health has proposed the
term minimal memory impairment to describe normal age-related cognitive
changes (J. A. Yesavage, Lapp, & Sheikh, 1989). Similar terms include age-asso-
ciated memory impairment (Crook et a1., 1986), normal cognitive aging (Powell,
1994), and benign senescent forgetfulness (Jarvik, 1980). Although efforts have
been made to develop criteria to define normal memory aging (Crook &
Larrabee, 1988), systematic application of these criteria by researchers and clin-
icians has yet to occur. Widespread endorsement of a topology of the memory
problems of normal aging is a likely trend for the future; such a topology would
be beneficial for research and clinical purposes (Powell, 1994).
Normal Memory Aging 89
Pathological Memory Aging

Diagnostic Issues
An important issue for practicing clinicians is to distinguish memory prob-
lems of normal aging from those that may be caused by physiological or psy-
chopathological factors. Forgetting names of family members or close friends,
confusion in space and time, and difficulties with simple motor tasks (e.g., un-
locking a door with a key) are behaviors that could be signaling a serious health
condition. Accurate diagnosis of conditions producing problems such as these
is imperative. as cognitive deficits may be responsive to treatment in some
cases. However, deficits such as those observed in the adult dementias are irre-
versible (Jarvik, 1980).
Although numerous advances in the clinical assessment of memory in
older adults have been made in recent years (Poon et aI., 1986; Powell, 1994),
accurate diagnosis of memory dysfunction remains difficult. This is partly be-
cause many etiologically distinct conditions have similar behavioral symptoms
(e.g., dementia, cerebral vascular accident, nutritional and metabolic disorders,
head trauma). Consequently, extensive case histories, as well as concurrent
physical, clinical, and neurological examinations, may be necessary before de-
finitive diagnoses would be warranted (Jarvik, 1980).
Adult Dementias
Dementia syndromes are a form of organic mental disorders defined
broadly by a constellation of symptoms and features, including gross cognitive
impairment and changes in personality and affective states (American Psychi-
atric Association, 1994). Progressive memory dysfunction is symptomatic of
Alzheimer's disease (AD) and other dementia syndromes that affect older adults
(see Cherry & Plauche, 1996, for review). For example, Parkinson's disease (a
disorder involving loss of motor ability) has associated dementia in some cases,
with memory impairment and slowness of thinking, but preserved language
ability. Multi-infarct dementia is a vascular dementia with an abrupt onset,
stepwise deterioration, and focal neurologic signs and symptoms. Pick's dis-
ease, a rare dementing disorder, is clinically similar to AD but the neurochem-
istry and neuropathology differs by comparison Cruetzfeldt-Jakob disease is a
rare, infectious disorder (caused by a slow-acting virus) with pronounced men-
tal deterioration, involuntary muscle spasms, and rapid death. Confirmation of
diagnosis of the adult dementias occurs postmortem when specific neurologic
features are revealed on autopsy (Jarvik, 1980; Raskind & Peskind, 1992).
Physiological Conditions
Certain physiologic conditions have associated memory dysfunction that
may resemble early AD (Haase, 1971). Such conditions include but are not lim-
ited to normal-pressure hydrocephalus; metabolic, endocrine, or electrolyte dis-
turbances; and other conditions, such as dietary insufficiencies or alcoholism.
Diagnosis and treatment of these conditions are imperative, as it may be possi-

ble to reverse the cognitive deficits in some cases (Jarvik, 1980).
Pharmacological Agents
Older persons may experience multiple health problems and illnesses that are
treated with different drug therapies (e.g., auslander, 1981; Vestal, 1978). Physi-
cian-prescribed medications, as well as over-the-counter medications, may ad-
versely affect older adults' memory and other aspects of cognition. For example,
antimicrobials have been associated with memory disturbance in older persons.
Antihypertensives, analgesics, antihistamines, and cardiovascular medications
have also been shown to produce confusion (among other adverse effects) in older
persons (see auslander, 1982). Memory problems and confusional states due to
drug effects, drug-drug interactions, or drug toxicity can potentially be reversed.
Risks of adverse drug reactions can be minimized by careful monitoring and ap-
propriate adjustment of therapeutic dosages (Cherry & Morton, 1989).
Psychopathologic Conditions
Memory problems may also be due to conditions such as acute grief, para-
noid disorders, and depression. In fact, clinical depression may be initially mis-
taken for probable AD, due to the similarity of symptoms (e.g., apathy,
difficulties in concentration, psychomotor slowing). Depressed older adults
may complain of memory loss, but the correspondence between self-reported
memory deficits and objective memory performance tends to be poor (Kahn,
Zarit, Hilbert, & Niederehe, 1975; Larrabee & Levin, 1986; Popkin, Gallagher,
Thompson, & Moore, 1982). In contrast, probable AD patients may overestimate
their memory ability, relative to performance on objective memory tests and re-
ports by their relatives (Gilewski & Zelinski, 1986). Recent studies also indicate
that severe depression may coexist with AD in the early stages (e.g., Lamberty &
Bieliauskas, 1993). Further research is needed to clarify the conceptual and
methodological issues that surround dual diagnosis of depression and demen-
tia (Terry & Wagner, 1992).
FIVE CONCLUSIONS FROM EXPERIMENTAL

STUDIES OF NORMAL MEMORY AGING
Because memory problems associated with normal aging are so prevalent,

they have been very popular research topics in psychology. In fact, one third of
all published research studies examining psychological aging over the past two
decades have dealt with memory (Smith, 1996). Based on a selective review of
this literature, we offer five general conclusions: (1) the relationship between
aging and memory performance is complex; (2) individual differences within
age groups are often greater than differences between age groups; (3) noncogni-
tive factors may influence the magnitude of age differences in memory perfor-
mance, but these factors do not account for all the age-related variance in
memory performance; (4) much of the age-related variance in memory perfor-

mance can be accounted for by simple cognitive mechanisms; and (5) success-
ful aging is not the absence of memory changes but adaptation to them.
Description of Relationship Between Age and Memory
Memory changes associated with aging are complex and no simple de-
scription is satisfactory. To illustrate, Table 6-1 presents a summary of age ef-
fects on different types of short-term and long-term memory tasks. As can be
seen in Table 6-1, changes associated with some types of memory are large and
reliable, while others are negligible. Even a distinction between short-term
memory and long-term memory is not sufficient to capture the complexities as-
sociated with the effects of aging.
Short-Term Memory
With short-term memory, it is not the passive capacity to keep things in
mind that is affected by aging (Le., primary memory), but rather the capacity to
store and process at the same time (Le., working memory) (Dobbs & Rule, 1989).
The Forward Digit Span test on the Wechsler Adult Intelligence Scale (WAIS)
provides an estimate of primary memory. Age differences are typically not
found on this test, unless a very large number of subjects is used making the age
comparisons powerful enough to detect very small differences (Craik & Jen-
nings, 1992). Active working memory tasks, however, do show reliable age dif-
ferences. Regardless of whether the working memory tasks involve processing
verbal materials (e.g., Wingfield, Stine, Lahar, & Aberdeen, 1988), arithmetic
problems (e.g., Babcock & Salthouse, 1990), or spatial information (e.g., Salt-
house, 1993), older adults consistently do worse when trying to store and
process information at the same time.
Long-Term Memory
Age effects on long-term memory are also specific to certain types of mem-
ory. While semantic and procedural memory are relatively spared, there are
deficits in episodic memory in older adults.
Semantic memory involves the ability of subjects to recall information from
their accumulated world knowledge. There is some evidence that it takes longer
for older adults to retrieve semantic information, but there is little evidence that
this reflects a problem with the structure or quality of semantic memory storage
(e.g., Light, 1992). For example, when the structure of semantic memory (Le.,
the nature of the network of semantic associations) is assessed by looking at the
ability of different-aged subjects to generate free associations across a variety of
different types of materials, there are no age differences in the nature of the as-
sociations given (Light, 1991, 1992).
Procedural memory refers to remembering that is automatic, memory without
the requirement of deliberate recollection. Procedural memory ability requires
Table 6·1. Description of Memory Types and Age Effects on Memory Tests
Type of memory Definition Example test Age effects
Short-term memory
Primary memory Passive capacity to WAIS Forward Digit Little age effects; age
keep things in mind; Span differences only
the number of detected if large
things one can think number of adults
of at one time. tested.
Working memory Active capacity to store Reading span; read Large. reliable age
information and sentences and an- differences regard-
process information swer questions less of type of pro-
at the same time; the about each sen- cessing involved.
ability to engage in tence; when cued. Deficits seen with
on-line information recall the last word semantic. spatial. or
processing. in each sentence. computational pro-
cessing.
Long-term memory
Episodic memory Ability to remember Free recall task; look Large. reliable age
past experiences at a list of familiar differences in recall;
based on contextual words and later re- smaller age differ-
cues associated with call as many of the ences if recognition
original learning. words as possible. used to test memory.
Semantic memory Ability to retrieve WAIS Vocabulary Test No age differences

information as or General Informa- unless large number
world knowledge tion Test of adults tested and
based on semantic then slight advan-
or conceptual cues. tage for older adults
over younger adults.
Procedural memory Automatic skill. Can Implicit memory test; Little age effects in im-
be complex skill view list of words plicit memory;
(e.g .• riding a bicy- and then later fill in slight differences
de) to simple indi- stem completions detected in favaor of
rect effects of with words (e.g .• younger adults if
memory (e.g .. ST__ ). Words large numbers of
implicit memory). from earlier read list subjects used to test
are filled in even for implicit memory.
though subjects are
unaware of the
much practice to make remembering automatic, but there is general consensus that
if memories are automatic, age differences are negligible (Hasher & Sacks, 1979).
Procedural memories can range from indirect effects of memory to complex skills
like riding a bicycle or driving a car.
A good example of procedural knowledge is implicit memory, a measur-
able effect of previous experience (Le., memory) without awareness on the part
of the subject. A typical demonstration of implicit memory involves presenting
a list of words without an indication that a test will follow. Following some
filled time interval, subjects are asked to supply the first word that comes to
mind to a stem completion (st__ or a word fragment (p_r_di_m). Subjects will

give words presented in the earlier list, even though they are unaware that the
words came from the other list, and even though they cannot remember the
words in an explicit recall test. Evidence suggests that there are very small age
differences in implicit memory, if any at all (see Howard, 1996, for review). Al-
though some researchers have found small but significant age differences in im-
plicit memory, many subjects are necessary to show these differences because
of the small effect sizes (e.g., Hultsch, Masson, & Small, 1991).
In contrast to semantic and procedural memory, episodic memory, which
reflects memory for information experienced in specific contexts, shows age
differences. The size of these deficits, however. seems to be dependent on the
degree of subject-initiated processing required in the task (Craik, 1986). At both
encoding (learning) and retrieval (remembering), age differences in episodic
memory can be lessened by reducing the processing requirements of the task.
For example, in a paired-associate memory task, age differences are smaller if
the stimulus and response items are related to each other and larger if they are
unrelated as the subject must generate an association between them (e.g., Park,
Smith, Morrell, Puglisi, & Dudley, 1990).
Research on age differences in memory for pictures also supports the view
that the processing requirements inherent in the memory task determine the
magnitude of age effects. Age differences are found on several tasks that use pic-
torial materials (e.g., memory for faces, Bartlett, Leslie, Tubbs, & Fulton, 1989;
map routes, Lipman & Caplan, 1992; simple line drawings, Puglisi & Park,
1987). However, age differences are typically not found with recognition of
complex pictorial scenes (e.g., Park, Puglisi, & Smith, 1986). It has been shown
that older adults do as well as younger adults in remembering complex scenes
because of the rich semantic and perceptual detail found in such pictures
(Smith, Park, Cherry, & Berkovsky, 1990). When the pictures were made non-
meaningful or abstract, or when perceptual detail was removed from the pic-
tures, age differences emerged. Again, the rich encoding context provided by
the complex scenes may minimize the processing requirements to encode and
later remember the pictures.
Similarly, reducing the effort or processing requirements at retrieval can re-
duce age differences on episodic tasks. Craik and McDowd (1987), for example,
found large age differences when episodic memory was tested by free recall, but
no age differences when memory was tested by recognition (picking out the
words that were presented earlier), even when the overall level of performance
on recall and recognition were equated by differentially delaying the recogni-
tion test. Craik and McDowd also measured the processing effort required of the
two retrieval tasks by having subjects perform a digit-monitoring task while
they were remembering the words. Slowed reaction time (RT) on the digit task
indicates greater effort in the word-retrieval task because subjects have to time-
share their attention to the two tasks (retrieving the words and monitoring the
digits). The RTs of younger subjects were similar for the recall and recognition
tasks. The older adults, however, doubled their RTs when trying to recall the
items as compared to recognition. This suggests that the older adults do worse
on the recall task because of the greater effort required to retrieve the words.
Summary and Implications

In short, age differences in memory depend on the nature of the memory
test, the information to be remembered, and the type of memory being tested.
Age differences in memory are not always found, but seem to be determined by
the degree of self-initiated processing required.
For the clinician, it is important to understand that memory changes associ-
ated with normal aging are selective and that only certain memory tasks and
types of memory show age differences. This allows better discrimination be-
tween memory complaints of realistic perceived changes associated with normal
aging, and memory complaints that reflect other problems such as depression.
Use of tasks that show minimal age effects, such as implicit (procedural) or se-
mantic memory, also may be useful in differentiating normal memory changes
from cognitive pathologies associated with dementia. Making such differentia-
tions is complex, however, because demented patients show deficits on some
procedural and semantic tasks but not others (e.g., Nebes, 1992).
Furthermore, understanding that memory differences are largest when self-
initiated deliberate processing is required can be used to structure environ-
mental interventions that minimize memory problems in older adults. As
examples, Park (1992) discusses how theoretical and empirical findings from
the memory laboratory can be used to help with everyday problems specific to
older adults, such as medication adherence or work productivity.
Individual Differences Increase with Age

General
Although mean performance on many memory tasks decreases with age, it
is evident that variance in performance increases. In fact, individual differences
in memory performance within an age group are often larger than mean differ-
ences between age groups. This was demonstrated by Powell (1994) in his study
of the cognitive performance of 1,002 physicians ranging in age from 25 to 92
years. Twenty-two different cognitive tests from simple reaction time (RT) to
analogical reasoning were administered to the physicians. Many of the tests in-
volved measures of memory, such as word recognition, story recall. and spatial
recall. There was a steady decline in overall cognitive performance across the
age groups, and this overall effect was replicated with each of the separate
memory measures. More striking, however, was the increase in variability of
performance. Even though the performance at age 70 was 18% lower than
among the 40-year-olds, variability in performance was 60% greater. Similar re-
sults have been reported by other investigators. This indicates that the rate of
memory decline differs considerably among individuals.

Because of the magnitude of individual differences and the fact that individ-
ual differences tend to increase with age, it is difficult to assess memory perfor-
mance without longitudinal measures (measures of individual change). In fact,
because memory pathology associated with dementia is characterized by degen-

erative change, care must be taken to make multiple assessments across time
when early signs of dementia are suggested. Only late in dementia are qualitative
differences seen between normal aging and pathological aging (Nebes, 1992).
Noncognitive Influences on Age-Related Memory Differences

General
It has been popular to attribute age differences on memory tasks to factors
other than aging per se (e.g., student status, self-reported health, depression).
Factors that have been hypothesized to account for age differences in memory
include education (e.g., Kaufman, Reynolds, & McLean, 1989), metamemory
(see Light, 1991, for review), and motivation (e.g., Hartley & Walsh, 1980). Over-
all, however, research has failed to show that these factors can account for sig-
nificant age-related variance.
One hypothesis has been that laboratory memory tasks are more similar to
academic remembering required in formal school settings and less like the
everyday memory requirements of older adults (e.g., Perlmutter & Mitchell,
1982). Htrue, many ofthe memory differences would be exaggerated especially
because many laboratory studies compare community-dwelling older adults to
younger college students. Even though some studies have found that age differ-
ences in memory tasks are reduced when student status is controlled (e.g., com-
paring young vs. old college students), there are many problems with such
comparisons. Often, for example, older students are taking elective single
courses rather than being engaged in full academic pursuits (e.g., Zivian &
Darjes, 1983). Furthermore, the findings are not consistent. Other studies have
found significant age differences in memory performance when student status
is controlled (e.g., Cohen, Sandler, & Schroeder, 1987).
Another factor that is obviously important in determining memory is
health. Because health problems increase so dramatically with aging, health has
been a likely factor producing the observed age differences in memory tasks.
There have been conflicting results when self-rated health is used to account for
age-related variance in cognitive performance. Some researchers have found
that age-related variance is reduced when health is considered (e.g., Perlmutter
& Nyquist, 1990), while others show no change at all when health is controlled
(e.g., Salthouse, Kausler, & Saults, 1990). Health status, at best, accounts for
only a part of the age-related memory variance.
Statistics also show depression to be more prevalent in older adults (e.g.,
Blazer, Hughes, & George, 1987). Depression, however, is sometimes difficult to
diagnose because of the symptoms that may be associated with normal aging such
as complaints about memory failures. In fact, evidence suggests that memory com-
plaint may be more predictive of a lack of memory self-efficacy and depression
than of actual memory performance (Larrabee & Levin, 1986). When validating
commonly used metamemory questionnaires, Hertzog, Hultsch, and Dixon (1989)
found a significant relationship between memory self-efficacy as measured on
these questionnaires and measures of depression and well-being. Furthermore,
West, Crook, and Barron (1992) found that age still predicted everyday memory
performance, even when scores on a test of depression were statistically controlled.

Changes in memory are real. So far, research has been unable to attribute
these changes solely to factors other than aging. Thus, it is important for older
adults to understand that memory change is normal and not reflective of either
lack of motivation or the beginnings of dementia. Although noncognitive fac-
tors such as motivation, affect, education, socioeconomic status, experiences
due to birth cohort, and physical and mental health have been shown to influ-
ence cognition, no research to date has shown that any single factor is primar-
ily responsible for age-related memory differences (see Salthouse, 1991).
Simple Cognitive Mechanisms as Predictors of Age-Related

Memory Differences
General
Although noncognitive factors have proven unsuccessful in accounting for
the age-related memory differences seen in normal aging, a few cognitive mech-
anisms are good predictors of these differences. Earlier, it was indicated that
memory differences in laboratory tasks seem to be determined by the extent of
effort or deliberate processing required for the task. Even though no direct mea-
sures of deliberate processing have been developed, several specific measures
have proven effective.
As discussed earlier, working memory is assumed to reflect the capacity to
engage in on-line information processing (see Table 6-1). Because of the funda-
mental importance of working memory to cognition, researchers have at-
tempted to determine whether individual differences in working memory
predict age-related variance in other cognitive tasks. Salthouse (1992), in a re-
view of a large number of studies examining the relationship among age, work-
ing memory, and cognition, has shown that about 50% of the age-related
variance in cognition across a variety of different cognitive tasks is shared with
working memory capacity. Other evidence indicates that measures of working
memory account for a large proportion of the age-related variance in episodic
memory performance. For example, Hultsch, Hertzog, and Dixon (1990) showed
that working memory capacity accounts for much of the age difference in both
word recall and text recall.
Other studies have shown that even simple measures of perceptual speed
can account for the large proportion of the age-related variance in memory per-
formance. When performance on perceptual speed tasks such as the digit-sym-
bol substitution test or even simple perceptual comparison tasks (deciding
whether digit or letter strings are the same or different) is statistically controlled,
very little age-related variance remains on most memory measures. Salthouse
(1994), for example, found that only 1 % of the age-related variance on paired-
associate memory was unique to age and not shared with perceptual speed. In
one recent study, Park and colleagues (1996) found that perceptual speed ac-
counted for most of the variance in free recall, cued recall, and spatial memory
(three episodic memory tasks that show reliable age differences in the literature).

Individual difference studies show that even though interactions between
age and various memory tasks are complex, cognitive mechanisms such as
speed and working memory capacity may be responsible for much of the age-
related variance. This research supports an inviting hypothesis that a few num-
ber of simple mechanisms may be responsible for most of the memory differ-
ences experienced by older adults. As Park (1992) points out, this means that
greater attention needs to be paid to the environmental conditions faced daily
by older adults that require complex, rapid decision making.
Successful Aging Is Not the Absence of Change but Adaptation to It
Baltes and Baltes (1990) propose a model of psychological aging that holds
that successful aging is not the absence of psychological change, but the extent
to which older adults are able to handle change (see Figure 6-1). As can be seen
in the model, through various adaptive processes older adults can lead effective
lives in the presence of cognitive loss. As we grow older, we are capable of a
great deal of adaptation. For example, training studies show that there is a great
deal of plasticity in cognitive processes with age. Willis and her colleagues have
shown that even fluid intelligence skills can be improved in older adults with
training (see Willis, 1989, for review). Others have shown that specific cognitive
losses are often compensated for by improvements in other processes that
Antecedent Conditions Processes Outcomes
Life Development as
Specialized and age- Reduced
graded Adaptation and
Selection Transformed
Reduction in General __
Optimization .....
~ .. but
Reserve Capacity --- Compensation Effective
Life
Losses in Specific
Function
-I
Figure 6-1. The Baltes and Baltes (1990) model of selective optimization with compen-
sation, a model of adaptation during aging leading to successful aging. From "Psycho-
logical Perspectives on Successful Aging: The Model of Selective Optimization with
Compensation," by P. B. Baltes and M. M. Baltes, 1990. In P. B. Baltes and M. M. Baltes
(Eds.), Successful Aging: Perspectives from the Social Sciences. Cambridge: Cambridge
University Press. Copyright 1990 by Cambridge University Press. Adapted with permis-
sion from P. B. Baltes.
together determine some overall cognitive behavior (Charness & Bosman, 1990).
Salthouse (1984), for example, found that some expert typists will maintain
their overall typing speed late into life, despite the fact that perceptual-motor
speed (measured by choice RT) declines significantly. He discovered that the
increases in RT were compensated for by the fact that the export typists had
learned to look further ahead in the text while typing (eye-hand span).
To summarize, memory changes in normal aging are complex and individ-
ual differences tend to be large. Age-related differences in memory cannot be
wholly accounted for by noncognitive variables, but can be predicted by simple
cognitive mechanisms. Older adults are also capable of engaging in compen-
satory and optimization activities that greatly attenuate the effects of memory
change on their daily lives.
MEMORY INTERVENTIONS
Researchers have attempted to offset age deficits in memory by training

older adults in the use of mnemonic techniques to improve recall. Generally
speaking, most mnemonic methods are efficacious for older adults, relative to
baseline or appropriate control group conditions. Most studies on mnemonic
methods have used visually based imagery and the classic mnemonic tech-
niques (see Poon, Walsh-Sweeney, & Fozard, 1980, and J. A. Yesavage et al.,
1989, for reviews), as described next. Interested readers are referred to other
sources where verbally based mnemonic methods are discussed (Drevenstedt
& Bellezza, 1993; Hill, Allen, & McWhorter, 1991).
Classic Mnemonic Techniques

Visual Imagery
The philosophical origins of visual imagery as an aid to memory are traced
back to the writings of Aristotle and other classical scholars of rhetoric (Paivio,
1971). In the commercial realm, modem-day memory professionals and authors
of popular psychology books stress visually imaging the material to be remem-
bered to promote recall (e.g., Bellezza, 1982; Bezan, 1974; Lorayne & Lucas,
1974). For example, Roth (1961) has argued that creative visualization is the
sine qua non of good memory. His three cardinal principles are exaggeration,
motion, and unusual association. To remember the noun pair hen-ham, Roth
suggests visualizing "a big ham in the yard." "A large hen runs and jumps on
the ham and dances a jig there" (p. 8).
In short, the popular idea has been that implausible, imaginative associations
enhance recall. Experimental studies in the verbal learning tradition have docu-
mented the positive effects of visual imagery on retention (e.g., Bower, 1972).
However, studies of imagery bizarreness with college students have yielded
equivocal results (e.g., Kroll, Schepeler, & Angin, 1986; McDaniel & Einstein,
1986). Few studies have examined image bizarreness effects with older adults
(Poon et aI., 1980). Crovitz (1989) has made the point that younger adults may be
comfortable with forming bizarre images of stimuli to be recalled, but older peo-
ple would prefer to form plausible associations. Thus, in contrast to the popular
literature, it seems more appropriate to endorse the formation of plausible rather
than bizarre imagery to increase the likelihood of recall in older people.
Substantial evidence shows that imagery-based mnemonics improve recall
in younger adults (e.g., word lists, Roediger, 1980; face-name associations, Mc-
Carty, 1980). For older adults, positive effects of imagery have been revealed in
studies of paired-associate learning (e.g., Hulicka & Grossman, 1967) and mem-
ory for face-name associations (e.g., J. A. Yesavage & Rose, 1984a). It is clear that
older adults benefit as do younger adults from visual imagery as a mediator in
learning and memory. Thus, the assumption has been that older people should
also profit from mnemonic techniques, such as the method of loci and pegword
method, that incorporate visual imagery and other procedures that improve the
organization of the material to be remembered.
Method of Loci
The method of loci is a classic mnemonic technique that was first used by
ancient scholars to remember their long orations. This technique involves using
a well-known sequence of spatial locations to store issues in a speech, or word
lists to be remembered by imagining separate items in each location. Items are
recalled in the correct sequence by visualizing each location and its contents
(Bower, 1970).
Ample evidence confirms the benefit of the method of loci in word list re-
call for college students (e.g., Groninger, 1971; Ross & Lawrence, 1968) and
older adults (e.g., Anschutz, Camp, Markley, & Kramer 1985; Hill, Yesavage,
Sheikh, & Friedman, 1989; J. A. Yesavage & Rose, 1984b). The size of the mem-
ory benefit, however, tends to be smaller for older adults when compared with
younger persons (Kliegl, Smith, & Baltes, 1990; Lindenberger, Kliegl, & Baltes,
1992; Robertson-Tchabo, Hausman, & Arenberg, 1976; but see Rose & Yesavage,
1983). Robertson-Tchabo and colleagues (1976) also found that older people
were unlikely to use the method of loci unless experimenter-prompted. Simi-
larly, Anschutz, Camp, Markley, and Kramer (1987) found that older adults ac-
knowledged the efficacy of the method of loci after training, but seldom used
the method in everyday life.
Pegword Method
The pegword method is similar to the method of loci in that both techniques
use visual imagery to enhance serial recall of word lists. The pegword method
requires subjects to first memorize a sequence of number-rhyme pairs (e.g., "one
is a bun, two is a shoe ... "). The numbers (1-10) are paired with simple concrete
nouns which invoke visual images that provide a "peg" for the items to be re-
called. Following training on the number-rhyme pairs, subjects are told to form
a complex image where each word to be recalled interacts with its correspond-
ing pegword (e.g., "battleship in bun," see Bugelski, Kidd, & Segmen, 1968). At
recall, subjects mentally reinstate the number-rhyme sequence; successive peg-
words should prompt a compound image of the pegwords' referent interacting
with the word to be recalled (e.g .. "one is a bun" ~ battleship in a bun). The
mnemonic efficacy of this technique is derived from both the pegword, which
serves as a retrieval cue, and the numbers, which permit serially ordered recall
(Paivio, 1971).
The effectiveness of the pegword mnemonic for college students is widely
recognized. For example, Bugelski and colleagues (1968) found that linking the
items to be remembered with the pegwords in an interactive relationship led to
greater recall relative to both rhyme and standard control group conditions. Later
studies show that the benefit extends to multiple list learning (e.g., Bower & Re-
itman, 1972; Persensky & Senter, 1970). Studies with older adults have failed to
show positive effects of the pegword mnemonic on learning and memory (Mason
& Smith 1977; Wood & Pratt, 1987). Consequently, the pegword method has
since received scant attention in experimental aging literature (Kausler, 1994).
Improving the Effectiveness of Mnemonic Methods

Efforts to improve the effectiveness of imagery mnemonics for older adults
have been made by adding various instructional sessions to the program admin-
istered prior to training on the mnemonic method. Pretraining sessions have in-
cluded both cognitive (image elaboration) and noncognitive (affective judgments,
relaxation training) activities that have known or assumed beneficial effects on
memory (e.g., J. A. Yesavage et a1., 1989). The studies summarized next show the
positive effects of stimulus elaboration and confirm that pretraining generally im-
proves the effectiveness of the mnemonic technique for older persons.
J. A. Yesavage (1983) found that training older persons in forming visual im-
ages prior to mnemonic training improved face-name recall more than that of
nonspecific pretraining on improving attitudes toward aging. In a later study,
J. A. Yesavage and Rose (1984b) used a semantic orienting task (pleasantness
judgment) to increase elaboration of the visually imagined associations formed
during training with method of loci. They found that semantic elaboration en-
hanced older adults' recall of list items more than did standard mnemonic in-
structions (see also J. A. Yesavage, Rose. & Bower, 1983). These findings replicate
other studies showing a positive effect of semantic encoding tasks on memory
for visual stimuli (e.g., Bower & Karlin, 1974; Smith & Winograd, 1978).
Yesavage and his associates have also examined the effects noncognitive
pretraining activities on standard free recall (J. A. Yesavage, Rose, & Spiegel,
1982) and on mnemonic training efficacy (e.g., Hill, Sheikh, & Yesavage, 1989;
J. A. Yesavage & Jacob, 1984). For example, J. A. Yesavage and colleagues (1982)
found that progressive muscle relaxation pretraining had no effect on overall
word list recall but the two variables were positively correlated. That is, relax-
ation improved recall for older persons with initially high state anxiety (indi-
cated by anxiety subscale scores on the Symptom Check List 90), but impaired
recall for those low in anxiety (see Yesavage & Jacob, 1984, for similar results).
Recent studies with older adults have compared the effects of different
types of pretraining activities on face-name mnemonic training. Gratzinger,
Sheikh, Friedman, and Yesavage (1990) compared three pretraining activities
(imagery alone, imagery plus affective judgment, relaxation) given prior to in-
struction on a face-name mnemonic technique. Results showed that pretraining
enhanced recall, relative to baseline, but no differences occurred as a function

of the type of pretraining activity (see also Hill, Sheikh, et al., 1989; J. Yesavage,
Sheikh, Friedman, & Tanke, 1990; but see Hill, Sheikh, & Yesavage, 1988).
Moreover. Sheikh, Hill, and Yesavage (1986) found that the benefit of pre-
training activities was observed at immediate testing and at 6-month posttest.
Together, these studies suggest that pretraining activities improve the effective-
ness of face-name mnemonics and that the benefit is temporally stable (cf. Ver-
haeghen, Marcoen, & Gossens, 1992).
Cautionary Note
Several limitations in the use of visual imagery to promote recall in older
adults warrant brief mention. First, older adults may find the formation of com-
plex visual images difficult. This is not surprising because the encoding
processes required by imagery-based techniques may exceed the processing ca-
pabilities of older people. Second, visual imagery techniques may also be anx-
iety-provoking for older persons, especially in the context of testing situations
(see J. A. Yesavage et aI., 1989). Third, visually based mnemonic techniques are
complicated and often require extensive training to master. Thus, they may not
be useful for cognitively impaired, older persons or those who are unwilling to
participate in multiple training sessions (J. A. Yesavage et aI., 1989).
Memory Interventions with Cognitively Impaired Persons
Visual Imagery
Imagery mnemonics have been used with some success in cognitive reme-
diation programs for adults with neurological disorders (see Po on et al., 1980).
There is also evidence from a single case study showing that an imagery
mnemonic promoted retention of face-name associations for a probable AD pa-
tient (Hill, Evankovich, Sheikh, & Yesavage, 1987). However, Backman, Josephs-
son, Herlitz, Stigsdotter, and Viitanen (1991) later found that the same imagery
mnemonic enhanced face-name retention for one AD patient, but not for seven
other dementia patients, suggesting that the generalizability of mnemonic effect
is limited. Group studies with older adults have also revealed that the benefit of
visual mnemonic methods is positively correlated with cognitive status, as in-
dexed by scores on the Mini-Mental State Examination (Folstein, Folstein, &
McHugh, 1975; see Hill, Yesavage, et a1., 1989; J. Yesavage et a1., 1990). Thus, for
older persons with mild to moderate cognitive impairment, imagery mnemonics
may not be suitable, because of the limited processing resources of these persons
and the complexity ofthe mnemonic methods (Hill, Yesavage, et a1., 1989).
Spaced Retrieval
The spaced retrieval technique involves successive recall attempts at ex-
panding intervals following acquisition. The technique is based on earlier re-
search with college students in which lengthening the amount of time between
recall attempts improved performance more than that of constant repetition

within fIxed periods of time (cf Landauer & Bjork. 1978). The mnemonic bene-
fit of spaced retrieval for recall of simple associations has been demonstrated
for persons with neurological disorders (e.g .. Schacter. Rich & Stampp. 1985)
and older adults with probable AD (e.g .. Camp, 1989).
Camp and his associates (1989) adapted the spaced retrieval technique for
use with probable AD patients. During training trials, subjects were given spe-
cifIc target information to remember, such as a face-name association. Immedi-
ate recall was solicited. If recall was successful, the intertrial interval was
systematically expanded (e.g., 5-, 10-, 20-, and 40-second intervals, expanding
in increments of 30 seconds thereafter). Following a recall failure, the intertrial
interval was reduced to that of the previous trial. Using this procedure, Camp
and his associates successfully increased the duration ofretention of simple as-
sociations in probable AD patients from minutes to weeks after initial acquisi-
tion (see Camp & McKitrick, 1992; Kotler-Cope & Camp, 1990, for reviews). The
efficacy of spaced retrieval with demented adults has been attributed to implicit
memory processes, thought to be spared until the later stages of AD (e.g., Camp
et a1., 1993). Spaced retrieval techniques may be optimal for older adults with
probable AD, who would otherwise be unlikely to profit from the more cogni-
tively demanding imagery-based mnemonic methods.
Beyond the Laboratory: Application of Memory Interventions

with Older Adults
The notion that experimental mnemonic methods could be adapted for clin-
ical use has received a fair amount of attention (see Poon, 1985). Successful ap-
plication of mnemonic methods for everyday remembering is likely to depend
on careful consideration of many variables, such as individual difference and
task factors that may affect the outcome of mnemonic training, as discussed next.
Subject Characteristics
Whether a person will benefit from mnemonic training is an important
practical issue. Many different subject factors could limit the usefulness of vi-
sually based mnemonics applied to problems of everyday memory (e.g., age,
cognitive status, motivation, state anxiety, depression). Age and cognitive sta-
tus have been clearly shown to influence the success of mnemonic training
(e.g., J. Yesavage et aI., 1990). Less cognitively demanding techniques may be
more benefIcial for the oldest-old (those over 85 years) and persons with prob-
able AD. Based on the fIndings of Camp and his associates (1989), spaced re-
trieval appears to be an optimal technique for persons with probable AD.
Duration of Effects
Whether the benefIt of memory training will persist over time is another
important practical issue. Studies have examined the temporal stability of
both specific mnemonic methods (e.g., face-name training, Sheikh et al.,
1986; method ofloci, Anschutz et aI., 1987) and general memory skills train-
ing (Neely & Backman, 1993a, 1993b; Scogin & Bienias, 1988; Stigsdotter &
Backman, 1989). Some studies indicate that the benefit of memory training is
observed at 6-month follow-up (Neely & Backman, 1993a; Sheikh et aI., 1986;
Stigsdotter & Backman, 1989). Regarding long-term maintenance of effects,
the evidence has been equivocal. Scogin and Bienias (1988) found scant evi-
dence of overall training effectiveness at 3-year follow-up (d. Anschutz et al.,
1987). In contrast, Neely and Backman (1993b) found that performance gains
in word list recall were maintained at 31fz-year follow-up. That is, older adults
in the training program showed greater posttest recall (relative to pretest),
whereas performance did not vary across testing sessions for the nontrained
control group.
Contrasting outcomes for the durability of training effects over time may be
partly due to differences in subject samples and training procedures. In the Sco-
gin and Bienias (1988) study, those in the training program had significantly more
memory complaints than did the control group at both pretest and posttest.
TI:aining was also administered via self-instruction using a memory training man-
ual (d. Scogin, Storandt, & Lott, 1985). In contrast, Neely and Backman's (1993b)
program used training activities similar to those of Yesavage and his associates
(e.g., interactive imagery, attention and relaxation training; see Yesavage, Lapp, &
Sheikh, 1989). Interestingly, in both reports, there was no evidence of transfer of
training to other cognitive measures (digit span, Benton visual retention test).
Thus, extensive pretraining on task-relevant material may be necessary to pro-
mote long-term effectiveness of memory training programs in older adults.
Summary
Whether training programs will improve older adults' memory in daily life
may ultimately depend on noncognitive subject factors, such as compliance
and motivation. For example, older adults may modify the mnemonic method
after training or abandon it completely (Anschutz et aI., 1985, 1987). Neely and
Backman (1993a) found that only 39% of their sample reported using trained
mnemonic methods in everyday life at 6-month follow-up. Scogin and Bienias
(1988) reported a similar rate (28%) for self-taught memory skills at 3-year fol-
low-up. Future research is needed to identify noncognitive factors that predict
success with memory interventions (Yesavage et aI., 1989). In short, interven-
tion programs applied to everyday remembering should include posttraining
discussion sessions to encourage older adults to use and practice the techniques
they have learned, as older persons may not use these skills on their own ini-
tiative (Flynn & Storandt, 1990; Poon et al., 1980).
IMPLICATIONS FOR CLINICAL PRACTICE
Experimental studies of memory aging provide a rich source of knowledge

that is potentially useful for clinicians. In closing, we consider three broad im-
plications for clinical practice that arise from the experimental evidence pre-
sented earlier.
A Priori Beliefs About Memory Aging
People of all ages hold certain assumptions about the course of memory
abilities in adulthood. Culturally shared views of memory aging, as well as
everyday experience, may leave older persons with the impression that mem-
ory failures in later life are comprehensive and immutable. On the basis of ex-
perimental studies of memory aging, this assumption is largely inaccurate.
There are also theoretical and practical drawbacks to viewing memory in adult-
hood only in terms of progressive decline.
From a theoretical viewpoint, the universal-decrementalist perspective is
incompatible with evidence showing that age-related performance differences
are smaller on some cognitive tasks and larger on others (see Table 6-1). This
perspective is also antithetical to current views of cognitive plasticity in adult-
hood (e.g., Willis, 1989). From a practical viewpoint, a decrementalist perspec-
tive may foster the opinion that compensatory strategies and intervention
techniques are of limited value, which is clearly not true. The memory inter-
vention literature provides compelling evidence of cognitive remediation for
healthy older persons, and in some cases, for those with early AD. In short, neg-
ative a priori beliefs of memory competence in adulthood may thwart efforts to
improve everyday remembering, as well as limit the success to memory inter-
vention programs that are undertaken.
Examine Practical Memory Needs

Whether laboratory-based interventions are appropriately suited for meet-
ing the everyday memory needs of older persons has prompted some debate
(West, 1989). In general, very little research has examined older adults' practi-
cal memory needs (but see Leirer, Morrow, Sheikh, & Pariante, 1990). With re-
gard to clinical practice, defining the specific aspects of memory that an older
person might want to improve may be a useful starting place. Intervention tech-
niques could then be matched to self-expressed needs. For example, in ques-
tionnaire studies of everyday memory, older adults report difficulties in
learning and remembering names (e.g., Leirer et a1., 1990). In response to this
concern, visually based mnemonic methods could be applied, as numerous lab-
oratory studies confirm that these techniques improve recall of face-name
associations (Kausler, 1994; J. A. Yesavage et a1., 1989). In short, successful in-
tervention may depend on targeting everyday memory behaviors as indicated
by older persons. Specificity is especially important because there is very little
evidence of transfer of broad-based memory skills training to other cognitive
measures (ef. Neely & Backman, 1993a, 1993b).
Individual Differences and Clinical Outcomes
On the basis of the research summarized previously, it is likely that indi-

vidual differences contribute to clinical outcomes with older adults. For the
clinician, awareness of interindividual variability is vitally important for at
least two reasons. First, differences among older people are likely to influence
the choice of an appropriate treatment for memory problems. As West (1989)
has pointed out, memory interventions should be tailored specifically for the
individual. Some older persons may benefit from visual mnemonic methods
(see J. A. Yesavage et al., 1989). Others may have difficulty forming visual im-
ages and would prefer verbally based techniques, for example, those that em-
phasize categorical organization of material to be remembered (see Kausler,
1994). External memory aids (e.g., lists, notebooks) may also be preferable to in-
ternal mnemonic methods for some older adults (see Cavanaugh et al., 1983;
Crovitz, 1989). External aids could be used alone or in combination with inter-
nal mnemonic strategies to improve everyday remembering.
As a second point, individual differences are likely to affect clinical out-
comes. Appropriate criteria for everyday memory performance will vary from
one older person to another (J. A. Yesavage et al., 1989). Moreover, positive clin-
ical outcomes may have little to do with older adults' actual memory perfor-
mance. Some studies have shown no influence of mnemonic training on
memory performance, but other benefits of training were observed, such as im-
provements in perceived control (e.g., Lachman, Weaver, Bandura, & Lewkow-
icz, 1992) and reduced memory complaint (e.g., Zarit, Cole, & Guider, 1981; but
see Scogin & Bienias, 1988). Thus, memory intervention training may be useful
only to the extent that it reduces memory concerns and depression in some
older persons (Zarit, Gallagher, & Kramer, 1981).
SUMMARY
Ag.e-related declines in memory are well documented in experimental
studies with older adults. Whether age deficits will be minimal or exagger-
ated depends on characteristics of the memory task, the older person, and
the component mental processes involved in the act of remembering. Al-
though normal aging is associated with reduced memory efficiency, the
potential for remediation and cognitive compensation should not be over-
looked. As noted previously, adaptation to cognitive changes in adulthood
may be critical for successful aging (see Fig. 6-1). Practicing clinicians could
apply mnemonic methods or general principles of memory from the experi-
mental aging literature to assist older persons with adaptation to cognitive
changes in later life.
REFERENCES
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders
(4th ed.). Washington, DC: Author.
Anschutz, 1., Camp, C. J., Markley, R p, & Kramer, J. J. (1985). Maintenance and generalization of
mnemonics for grocery shopping by older adults. Experimental Aging Research, 11, 157-160.
Anschutz, 1., Camp, C. J., Markley, R. P., & Kramer, J. J. (1987). A three-year follow-up on the effects
of mnemonics training in elderly adults. Experimental Aging Research, 13, 141-143.
Babcock, R. 1., & Salthouse, T. A. (1990). Effects ofincreased processing demands on age differences
in working memory. Psychology and Aging, 5, 421-428.
Backman, L., Mantila, T., & Herlitz, A. (1990). The optimization of episodic remembering in old age.
In P. B. Baltes & M. M. Baltes (Eds.), Successful aging: Perspectives from the behavioral sci-
ences (pp. 118-163). New York: Cambridge University Press.
Backman, L., Josephsson, S., Herlitz, A., Stigsdotter. A.• & Viitanen, M. (1991). The generalizability
of training gains in dementia: Effects of an imagery-based mnemonic on face-name retention
duration. Psychology and Aging, 6, 489-492.
Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: The model of
selective optimization with compensation. In P. B. Baltes and M. M. Baltes (Eds.), Successful
aging: Perspectives from the behavioral sciences (pp. 1-34). Cambridge: Cambridge University
Press.
Bartlett, J. C., Leslie. J. E., Thbbs, A., & Fulton, A. (1989). Aging and memory of faces. Psychology
and Aging, 4, 276-283.
Bellezza, F. S. (1982). Improve your memory skills. Englewood Cliffs. NJ: Prentice-Hall.
Bezan, T. (1974). Use your perfect memory. New York: Dutton.
Blazer, D., Hughes, D. C., & George, 1. K. (1987). The epidemiology of depression in an elderly com-
munity sample. Gerontologist, 27, 281-287.
Bower, G. H. (1970). Analysis of a mnemonic device. American Scientist, 58,496-510.
Bower, G. H. (1972). Mental imagery and associative learning. In L. Gregg (Ed.), Cognition in learn-
ing and memory (pp. 51-88). New York: Wiley.
Bower, G. H., & Karlin, M. B. (1974). Depth of processing pictures of faces and recognition memory.
Journal of Experimental Psychology. 103, 751-757.
Bower. G. H .. & Reitman, J. S. (1972). Mnemonic elaboration in multi-list learning. Journal of Verbal
Learning and Verbal Behavior, 11,478-485.
Bugelski, B. R., Kidd, E., & Segmen, J. (1968). Image as a mediator in one-trial paired-associate learn-
ing. Journal of Experimental Psychology, 76, 69-73.
Camp, C. J. (1989). Facilitation of new learning in Alzheimer's disease. In G. C. Gilmore, P. White-
house, & M. Wylke (Eds.), Memory and Aging: Theory. research and practice (pp. 212-225).
New York: Springer.
Camp, C. J., & McKitrick, L. A. (1992). Memory interventions in Alzheimer's-type dementia popula-
tions: Methodological and theoretical issues. In R. L. West & J. D. Sinnott (Eds.), Everyday mem-
ory and aging: Current research and methodology (pp. 155-172). New York: Springer-Verlag.
Camp. C. J., Foss, J. W., Stevens, A. B., Reichard, C. C., McKitrick, L. A.• & O'Hanlon, A. M. (1993).
Memory training in normal and demented elderly populations: The E-I-E-I-O model. Experi-
mental Aging Research. 19,277-290.
Cavanaugh, J. C.• Grady, J. G., & Perlmutter, M. (1983). Forgetting and use of memory aids in 20 to
70 year olds in everyday life. International Journal of Aging and Human Development, 17,
113-122.
Charness. N., & Bosman. E. A. (1990). Expertise and aging: Life in the lab. In T. M. Hess (Ed.), Aging
and cognition: Knowledge, organization, and utilization (pp. 343-385). San Diego: Academic.
Cherry. K. E., & Morton, M. R. (1989). Drug sensitivity in older adults: The role of physiologic and
pharmacokinetic factors. International Journal of Aging and Human Development, 23,
159-174.
Cherry, K. E., & Plauche, M. F. (1996). Memory impairment in Alzheimer's disease: Findings, inter-
ventions. and implications. Journal of Clinical Geropsychology. 2, 263-296.
Cohen, R. L., Sandler, S. P., & Schroeder, K. (1987). Aging and memory for words and action events:
Effects of item repetition and list length. Psychology and Aging, 2, 280-285.
Craik, F. I. M. (1986). A functional account of age differences in memory. In F. Klix & H. Hagendorf
(Eds.), Human memory and cognitive capabilities. mechanisms, and performance (pp.
409-422). Amsterdam: Elsevier Science.
Craik, F. I. M., & Jennings, J. M., (1992). Human memory. In F. I. M. Craik & T. A. Salthouse (Eds.).
The handbook of aging and cognition (pp. 51-110). Hillsdale. NJ: Erlbaum.
Craik, F. I. M., & McDowd, J. M. (1987). Age differences in recall and recognition. Journal of Exper-
imental Psychology: Learning, Memory. and Cognition, 13.474-479.
Crook, T., & Larrabee, C. J. (1988). Age-associated memory impairment: Diagnostic criteria and treat-
ment strategies. Psychopharmacology Bulletin, 24, 509-514.
Crook, T., Bartus, R., Ferris. S. H., Whitehouse, P., Cohen, G., & Gershon. S. (1986). Age-associated
memory impairment: Proposed diagnostic criteria and measures of clinical change-Report of
a National Institute of Mental Health work group. Developmental Neuropsychology, 2,

261-276.
Crovitz, H. F. (1989). Memory retraining: Everyday needs and future prospects. In 1. W. Poon, D. C.
Rubin, & B. A. Wilson (Eds.), Everyday cognition in adulthood and late life (pp. 681-691).
New York: Cambridge University Press.
Dixon, R A. (1989). Questionnaire research on metamemory and aging: Issues of structure and func-
tion. In 1. W. Poon, D. C. Robin, & B. A. Wilson (Eds.), Everyday cognition in adulthood and
late life (pp. 394-681). New York: Cambridge University Press.
Dobbs, A. R, & Rule, B. G. (1989). Adult age differences in working memory. Psychology and Aging,
4,500-503.
Drevenstedt, J., & Bellezza, F. S. (1993). Memory for self-generated narration in the elderly. Psy-
chologyand Aging, 187-196.
Flynn, T. M., & Storandt, M. (1990). Supplemental group discussions in memory training for older
adults. Psychology and Aging, 5, 178-181.
Folstein, M. F., Folstein, S. E., & McHugh, P. H. (1975). Mini-Mental State: A practical method for
grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12,
189-198.
Gilewski, M. J., & Zelinski, E. M. (1986). Questionnaire assessment of memory complaints. In 1. W.
Poon, T. Crook, K. 1. Davis, C. Eisdorfer, B. J. Gurland, A. W. Kaszniak, & 1. W. Thompson
(Eds.), Handbook for clinical memory assessment of older adults (pp. 93-107). Washington,
DC: American Psychological Association.
Gratzinger, P., Sheikh, J. I., Friedman, 1., & Yesavage, J. A. (1990). Cognitive interventions to im-
prove face-name recall: The role of personality differences. Developmental Psychology, 26,
889-893.
Groninger, 1. C. (1971). Mnemonic imagery and forgetting. Psychonomic Science, 23, 161-163.
Haase, G. R (1971). Diseases presenting as dementia. In C. E. Wells (Ed.), Dementia (pp. 163-207).
Philadelphia: Davis.
Hartley, J. T., & Walsh, D. A. (1980). The effect of monetary incentive on amount and rate of free re-
call in older and younger adults. Journal of Gerontology, 35, 899-905.
Hasher, L., & Zacks, R T. (1979). Automatic and effortful processes in memory. Journal of Experi-
mental Psychology: General. 108,356-388.
Hertzog, C., Hultsch D. F., & Dixon, R A. (1989). Evidence for the convergent validity of two self-
report metamemory questionnaires. Developmental Psychology. 25, 687-700.
Hill, RD., Evankovich, K. D., Sheikh, J. I., & Yesavage, J. (1987). Imagery mnemonic training in a
patient with primary degenerative dementia. Psychology and Aging, 2, 204-205.
Hill, R D., Sheikh, J. I., & Yesavage, J. (1988). The effect of mnemonic training on perceived recall
confidence in the elderly. Experimental Aging Research, 13, 185-188.
Hill, R. D., Sheikh, J. I., & Yesavage, J. (1989). Pretraining enhances mnemonic training in elderly
adults. Experimental Aging Research, 14,207-211.
Hill, RD., Yesavage, J. A., Sheikh, J., & Friedman, L. (1989). Mental status as a predictor ofresponse
to memory training in older adults. Educational Gerontology, 15,633-639.
Hill, R. D., Allen, C., & McWhorter, P. (1991). Stories as a mnemonic aid for older learners. Psy-
chology and Aging, 6, 484-486.
Howard, D. (1996). The aging of implicit and explicit memory. In F. Blanchard-Fields & T. M. Hess
(Eds.), Perspectives on cognitive change in adulthood and aging (pp. 221-254). New York: Mc-
Graw-Hill.
Hulicka, I. M., & Grossman, J. L. (1967). Age group comparisons for the use of mediators in paired-
associate learning. Journal of Gerontology, 22, 46-51.
Hultsch, D. F., Hertzog, C., & Dixon, R A. (1990). Ability correlates of memory performance in
adulthood and aging. Psychology and Aging, 5, 356-368.
Hultsch, D. F., Masson, M., & Small, R A. (1991). Adult age differences in direct and indirect tests
of memory. Journals of Gerontology: Psychological Sciences, 46, P22-P30.
Jarvik, L. F. (1980). Diagnosis of dementia in the elderly: A 1980 perspective. Annual Review of
Gerontology and Geriatrics, 1, 180-203.
Kahn, H. 1., Zarit, S. H., Hilbert, N. M., & Niederehe, G. A. (1975). Memory complaint and impair-
ment in the aged: The effect of depression and altered brain function. Archives of General Psy-
chiatry, 32, 1560-1573.
Kaufman, A. S., Reynolds, C. R., & McLean, J. E. (1989). Age and WAIS-R intelligence in a national sam-
ple of adults in the 20 to 74-year age range: A cross-sectional study. Intelligence, 13,235-253.
Kausler, D. H. (1994). Learning and memoI)' in normal aging. San Diego, CA: Academic.
Kliegl, R., Smith, J., & Baltes, P. B. (1990). On the locus of magnification of age differences during
mnemonic training. Developmental Psychology. 26, 894-904.
Kotler-Cope, S., & Camp, C. J. (1990). Memory interventions in aging populations. In E. A. Lovelace
(Ed.), Aging and cognition: Mental processes. self-awareness and interventions (pp. 231-261).
Amsterdam: Elsevier Science.
Kroll, N. E. A., Schepeler, E. M., & Angin, K. T. (1986). Bizarre imagery: The misremembered
mnemonic. Journal of Experimental Psychology: Learning, MemoI)' and Cognition, 12,42-53.
Lachman, M. E., Weaver, S. L., Bandura, E., & Lewkowicz, C. J. (1992). Improving memory and con-
trol beliefs through cognitive restructuring and self-generated strategies. Journal of Gerontol-
ogy: Psychological Sciences, 47, P293-299.
Lamberty, G. J., & Bieliauskas, L. A. (1993). Distinguishing between depression and dementia in the
elderly: A review of neuropsychological findings. Archives of Clinical Neuropsychology. 8,
149-170.
Landauer, T. K., & Bjork, R. A. (1978). Optimum rehearsal patterns and name learning. In M. M.
Gruneberg, P. E. Morris, & R. N. Sykes (Eds.), Practical aspects of memoI)' (pp. 625-632). New
York: Academic.
Larrabee, G. J., & Levin, H. S. (1986). Memory self-ratings and objective test performance in a nor-
mal elderly sample. Journal of Clinical and Experimental, Neuropsychology, 8, 275-284.
Leirer, V. D., Morrow, D. G., Sheikh, J. I., & Pariante, G. (1990). Memory skills elders want to im-
prove. Experimental Aging Research, 17, 155-158.
Light, L. L. (1991). Memory and aging: Four hypotheses in search of data. Annual Review of Psy-
chology. 42, 333-376.
Light, L. L. (1992). The organization of memory in old age. In F. I. M. Craik & T. A. Salthouse (Eds.),
The handbook of cognition and aging (pp. 111-165). Hillsdale, NJ: Erlbaum.
Lindenberger, U., Kliegl, R., & Baltes, P. B. (1992). Professional expertise does not eliminate age dif-
ferences in imagery-based memory performance during adulthood. Psychology and Aging, 7,
585-593.
Lipman, P. D., & Caplan, L. J. (1992). Adult age differences in memory for routes: Effects of instruc-
tion and spatial diagram. Psychology and Aging, 7, 435-442.
Lorayne, H., & Lucas, J. (1974). The memoI)' book. New York: Stein and Day.
Mason, S. E., & Smith, A. D. (1977). Imagery in the aged. Experimental Aging Research, 3, 17-32.
McCarty, D. L. (1980). Investigation of a visual imagery mnemonic device for acquiring face-name
associations. Journal of Experimental Psychology: Human Learning and MemoI)', 6, 145-155.
McDaniel, M. A., & Einstein, G. D. (1986). Bizarre imagery as an effective memory aid: The impor-
tance of distinctiveness. Journal of Experimental Psychology: Learning, Memory. and Cogni-
tion, 12, 54-65.
Nebes, R. D. (1992). Cognitive dysfunction in Alzheimer's disease. In F. I. M. Craik & T. A. Salthouse
(Eds.), The handbook of aging and cognition (pp. 373-446). Hillsdale, NJ: Erlbaum.
Neely, A. S., & Backman, L. (1993a). Maintenance of gains following multifactorial and unifactorial
memory training in late adulthood. Educational Gerontology. 19,105-117.
Neely, A. S., & Backman, L. (1993b). Long-term maintenance of gains from memory training in older
adults: Two 3'/2 year follow-up studies. Journal of Gerontology: Psychological Sciences, 48,
P233-P237.
Duslander, J. G. (1981). Drug therapy in the elderly. Annals of Internal Medicine, 95, 711-722.
Ouslander, J. G. (1982). Illness and psychopathology in the elderly. In L. F. Jarvik & G. W. Small
(Eds.), Psychiatric clinics of North America (pp. 145-158). Philadelphia: Saunders.
Paivio, A. (1971). ImageI)' and verbal processes. New York: Rinehart and Winston.
Park, D. C. (1992). Applied cognitive aging research. In F. I. M. Craik and T. A. Salthouse (Eds.), The
handbook of aging and cognition (pp. 449-493). Hillsdale, NJ: Erlbaum.
Park, D. C., Puglisi, J. T., & Smith, A. D. (1986). Memory for pictures: Does an age-related decline ex-
ist? Psychology and Aging, 1,11-17.
Park, D. C., Smith, A. D., Morrell, R. W., Puglisi, J. T., & Dudley, W. N. (1990). Effects of contextual
integration in recall of pictures by older adults. Journals of Gerontology: Psychological Sci-
ences, 45, P52-P57.
Park. D. c.. Smith. A. D.. Lautenschlager. G.. Earles. J. 1.. Frieske. D.. Zwahr. M .. & Gaines. C. (1996). Me-
diators of long-term memory performance across the life span. Psychology and Aging. 11.621--637.
Perlmutter. M .. & Mitchell. D. B. (1982). The appearance and disappearance of age differences in
adult memory. In F. 1. M. Craik & S. Trehub (Eds.). Aging and cognitive processes (pp.
127-144). New York: Plenum.
Perlmutter. M .• & Nyquist. 1. (1990). Relationships between self-reported physical and mental
health and intelligence performance across adulthood. Journals of Gerontology: Psychological
Sciences. 45. P145-P155.
Persensky. J. J.• & Senter. R. J. (1970). An investigation of "bizarre" imagery as a mnemonic device.
Psychological Record. 20. 145-150.
Poon. 1. W. (1985). Differences in human memory with aging: Nature. causes. and clinical implica-
tions. In J. E. Bitten & K. W. Schaie (Eds.), Handbook of the psychology of aging (2nd ed .. pp.
427-462). New York: Van Nostrand Reinhold.
Poon.1. W.. Walsh-Sweeney. 1.. & Fozard. J. 1. (1980). Memory skill training for the elderly: Salient
issues on the use of imagery mnemonics. In 1. W. Poon. J. L. Fozard. 1. S. Cermak. D. S. Aren-
berg. & 1. W. Thompson (Eds.), New directions in memory and aging: Proceedings of the
George Talland memorial conference (pp. 461-484). Hillsdale. NJ: Erlbaum.
Poon.1. W.• Crook. T. Davis. K. 1.. Eisdorfer. C.• Gurland. B. J.• Kaszniak. A. w.. & Thompson. 1. W.
(1986). Handbook for clinical memory assessment of older adults. Washington. DC: American
Popkin. S. J.• Gallagher. D.. Thompson. 1. W.. & Moore. M. (1982). Memory complaint and perfor-
mance in normal and depressed older adults. Experimental Aging Research. 8. 141-145.
Powell. D. H. (1994). Profiles in cognitive aging. Cambridge. MA: Harvard University Press.
Puglisi. J. T.• & Park. D. C. (1987). Perceptual elaboration and memory in older adults. Journal of
Gerontology. 42. 160-162.
Raskind. M. A.. & Peskind. E. R. (1992). Alzheimer's disease and other dementing disorders. In J. E.
Birren. R. B. Sloane. & G. D. Cohen. Handbook of mental health and aging (2nd ed .. pp. 478-
513). New York: Academic.
Reisberg. B. Ferris. S. H .. deLeon. M. J.. Crook. T.• & Haynes. N. (1987). Senile dementia of the
Alzheimer's type. In M. Bergener (Ed.). Psychogenatrics: An international handbook (pp.
306-334). New York: Springer.
Robertson-Tchabo. E. A .. Hausman. C. P.• & Arenberg. D. (1976). A classical mnemonic for older
learners: A trip that works. Educational Gerontology. 1.215-226.
Roediger. H. L. (1980). The effectiveness of four mnemonics in ordering recall. Journal of Experi-
mental Psychology: Human Learning and Memory. 6. 558-567.
Rose. T. 1.. & Yesavage. J. A. (1983). Differential effects of a list-learning mnemonic in three age
groups. Gerontology. 29. 293-293.
Ross. Joo & Lawrence. K. A. (1968). Some observations on memory artifice. Psychonomic Science. 13.
107-108.
Roth. D. M. (1961). Roth memory course. New Jersey: Wehman.
Salthouse. T. A. (1984). Effect of age and skill in typing. Journal of Experimental Psychology. Gen-
eral, 13, 345-371.
Salthouse. T. A. (1991). Theoretical perspectives on cognitive aging. Hillsdale. NJ: Erlbaum.
Salthouse. T. A. (1992). Mechanisms of age-cognition relations in adulthood. Hillsdale. NJ: Erlbaum.
Salthouse. T. A. (1993). Influence of working memory on adult age differences in matrix reasoning.
British Journal of Psychology, 84, 171-199.
Salthouse. T. A. (1994). The nature of the influence of speed on adult age differences in cognition.
Developmental Psychology, 30, 240-259.
Salthouse. T. A.. Kausler. D. H .. & Saults. J. S. (1990). Age. self-assessed health status. and cognition.
Journals of Gerontology: Psychological Sciences, 45. P156-P160.
Schacter. D. 1.. Rich. S. A .. & Stampp. M. S. (1985). Remediation of memory disorders: Experimen-
tal evaluation of the spaced-retrieval technique. Journal of Clinical and Experimental Neu-
ropsychology. 7. 79-96.
Scogin. F. R.. & Bienias. J. 1. (1988). A three-year follow-up of older adult participants in a memory-
skills training program. Psychology and Aging, 3. 334-337.
Scogin. F. R.. Storandt. M .. & Lott. L. (1985). Memory-skills training. memory complaints. and de-
pression in older adults. Journal of Gerontology. 40. 562-568.
Sheikh, J. I., Hill, R. D., & Yesavage, J. A. (1986). Long-term efficacy of cognitive training for age-
associated memory impairment: A six-month follow-up study. Developmental Neuropsychol-
ogy. 2, 413-421.
Smith, A. D. (1996). Memory. In. J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of
aging (4th ed., pp. 236-250). San Diego, CA: Academic.
Smith, A. D., & Earles, J. L. K. (1996). Memory changes in normal aging. In F. Blanchard-Fields &
T. M. Hess (Eds.), Perspectives on cognitive change in adulthood and aging (pp. 192-220).
New York: McGraw-Hill.
Smith, A. D., & Winograd, E. (1978). Adult age differences in remembering faces. Developmental
Psychology, 14,443-444.
Smith, A. D., Park, D. C., Cherry, K. E., & Berkovsky, K. (1990). Age differences in memory for con-
crete and abstract pictures. Journals of Gerontology: Psychological Sciences, 45, P205-P209.
Stigsdotter, A., & Backman, L., (1989). Multifactorial memory training with older adults: How to fos-
ter maintenance of improved performance. Gerontology. 35, 260-267.
Terry, L., & Wagner. A. (1992). Alzheimer's disease and depression. Journal of Consulting and Clin-
ical Psychology, 60, 379-391.
Verhaeghen, P., Marcoen. A., & Gossens, L. (1992). Improving memory performance in the aged
through mnemonic training: A meta-analytic study. Psychology and Aging, 7, 242-251.
Vestal, R. F. (1978). Drug use in the elderly: A review of problems and special considerations. Drugs,
16,358-382.
West, R. L. (1989). Planning practical memory training for the aged. In L. W. Poon. D. C. Rubin, &
B. A. Wilson (Eds.), Everyday cognition in adulthood and late life (pp. 573-597). New York:
Cambridge University Press
West. R. L., Crook. T. H., & Barron, K. L. (1992). Everyday memory performance across the life span:
Effects of age and noncognitive individual differences. Psychology and Aging, 7, 72-82.
Willis. S. L. (1989). Improvement with cognitive training: Which old dogs learn what tricks? In
L. W. Poon, D. C. Rubin, & B. A. Wilson (Eds.), Everyday cognition in adulthood and late life
(pp. 545-569). New York: Cambridge University Press.
Wingfield, A., Stine, E. A. L., Lahar, C. J.. & Aberdeen, J. S. (1988). Does the capacity of working
memory change with age? Experimental Aging Research, 14,103-107.
Wood, I. E., & Pratt, J. D. (1987). Pegword mnemonic as an aid to memory in the elderly: A compar-
ison offour age groups. Educational Gerontology. 13, 325-339.
Yesavage, J., Sheikh, J. I., Friedman, L., & Tanke. E. (1990). Learning mnemonics: Roles of aging and
subtle cognitive impairment. Psychology and Aging, 5, 133-137.
Yesavage, J. A. (1983). Imagery pretraining and memory training in the elderly. Gerontology. 29, 271-275.
Yesavage, J. A., & Jacob, R. (1984). Effects of relaxation and mnemonics on memory attention and
anxiety in the elderly. Experimental Aging Research, 10,211-214.
Yesavage, J. A., & Rose, T. L. (1984a). The effects of a face-name mnemonics in young, middle-aged,
and elderly adults. Experimental Aging Research, 10,55-57.
Yesavage, J. A., & Rose. T. L. (1984b). Semantic elaboration and the method of loci: A new trip for
older learners. Experimental Aging Research, 10, 155-159.
Yesavage, J. A., Rose. T. L., & Spiegel, D. (1982). Relaxation training and memory improvement in
elderly normals: Correlation of anxiety ratings and recall improvement. Experimental Aging
Research, 8, 195-198.
Yesavage. J. A., Rose, T. L., & Bower. G. H. (1983). Interactive imagery and affective judgments im-
prove face-name learning in the elderly. Journal of Gerontology. 38, 197-203.
Yesavage, J. A., Lapp, D.. & Sheikh. J. I. (1989). Mnemonics as modified for use by the elderly. In
L. W. Poon, D. C. Rubin, & B. A. Wilson (Eds.), Everyday cognition in adulthood and late life
(pp. 598-611). New York: Cambridge University Press.
Zarit, S. H., Cole, K. D., & Guider, R. L. (1981). Memory training strategies and subjective complaints
of memory in the aged. The Gerontologist, 21, 158-164.
Zarit, S. H.• Gallagher, D., & Kramer, N. (1981). Memory training in the community aged: Effects of
depression, memory complaint, and memory performance. Educational Gerontology. 6, 11-27.
Zivian, M. T., & Darjes, R. W. (1983). Free recall by in-school and out-of-school adults: Performance
and metamemory. Developmental Psvchology. 19, 513-520.
PART II
PSYCHOPATHOLOGY,
ASSESSMENT, AND
TREATMENT
CHAPTER 7
Dementia
CHARLES J. GOLDEN AND
ANTONIA CHRONOPOLOUS
INTRODUCTION
Dementias were first recognized as a diagnostic issue during the 1800s and have
become a major topic only within the last half century. As the population has
aged, concern over the dementias has increased because of their higher inci-
dence and the increased sensitivity in medical and mental health circles in rec-
ognizing the symptoms of these disorders. Kraepelin (1896) saw dementia as a
disease of aging; later versions of his work recognized the writings of Alzheimer
(1898) and others who identified the presence of presenile dementias. Over
time, there has been increased attention to multiple etiologies and alternative
methods of presentation.
The dementias refer to a wide variety of disorders which are characterized
by memory problems along with at least one other cognitive problem. Demen-
tias may vary widely in terms of severity, course, nature of the symptoms, and
etiology. Dementias mayor may not be progressive, and vary in terms of treat-
ment, although they are characterized by irreversible declines in cognitive nmc-
tion. Age of onset may be at any time, but most dementias occur in the second
half of the life span.
Skoog, Nilsson, Palmertz, Andreasson, and Svanborg (1993) surveyed a
sample of 494, 85-year-old Swedes to determine relative incidence of dementia
in a nonselected population. The investigators, using a wide variety of diag-
nostic techniques, identified dementia in nearly 30% of their sample. Slightly
more than one fourth of these subjects had mild dementia, while the remain-
der were divided between mild and moderate dementia.
Several classification systems of the dementias have been employed. Cur-
rent classification systems recognize the dementias on the basis of the areas of
CHARLES J. GOLDEN AND ANTONIA CHRONOPOLOUS • Center for Psychological Studies, Nova Southeast-
ern University. Fort Lauderdale. Florida 33314.
113
114 Charles J. Golden and Antonia Chronopolous
the brain involved, or by etiology. For example, Gustafson (1992) classified de-
mentias into frontotemporal, temporoparietal, subcortical, or other types. Gott-
fries (1991) separated the dementi as into idiopathic dementi as (in which
dementia is the primary symptom of the disorder), vascular dementias. and sec-
ondary dementias (caused by trauma or substance abuse).
The Diagnostic and Statistical Manual of Mental Disorders, 4th edition
(DSM-IV; American Psychiatric Association, 1994) classified dementias in
terms of their specific etiologies: Dementia ofthe Alzheimer Type, Vascular De-
mentia, Dementia due to HIV Disease, Dementia due to Head Trauma, Demen-
tia due to Parkinson's Disease, Dementia due to Huntington's Disease, Dementia
due to Creutzfeldt-Jakob Disease, Dementia due to General Medical Conditions,
Substance Induced Persisting Dementia, Dementia due to Multiple Etiologies,
and Dementia Not Otherwise Specified (NOS).
Dementia-like symptoms may be seen in disorders classified as delirium. A
delirium may have similar symptoms, but the disorder is generally more vari-
able and the symptoms increase and decrease. While most cases of delirium are
time limited, especially when the etiology is recognized, this is not always the
case. Conversely, the symptoms in dementia are more stable or reflect deterio-
rating skills. However, some cases of dementia may be found to be treatable and
the symptoms may remit despite the fact that one may associate the word de-
mentia with the concept of irreversibility. Some disorders are initially classified
as deliriums, but are later found to be dementias, and disorders initially seen as
dementias may later be found to be cases of delirium.
DEFINITION
Regardless of etiology, all dementias are characterized by a primary loss in

memory functions. Without this essential feature, no set of symptoms, regard-
less of severity, can be classified as a dementia. However, in addition to the
symptoms of memory disturbance, there must be at least one other cognitive
symptom. This may be a disorder of language. a disorder of spatial skills, a dis-
order of social judgment, or a disorder of executive functions of the brain.
Memory Symptoms
The most obvious of the memory symptoms is the loss of the ability to learn
new material. This generally occurs early in the disorder and may be the first
symptom to become evident. In individuals with extensive previous learning,
this symptom may be masked as the individual may substitute previously
learned knowledge for the information one wishes the person to learn. In indi-
viduals with less previous knowledge, the loss of new learning may be more
evident although it may be mistaken in some cases for a generalized preexisting
slowness in learning.
Other cases may report loss of long-term, preexisting memories as well,
although there is some disagreement in this area; this loss is rare in mild cases.
Individuals may be unable to produce specific memories on command at a spe-
Dementia 115
cific time, but often later can relate the "forgotten" memory. In early cases,
losses are rarely seen in short-term memory, in which the individual cannot re-
tain information for several seconds or maintain a short conversation. However,
losses in these areas may be quite striking in more severe cases.
Related Cognitive Disorders
Related cognitive disorders may fall into many categories. Patients may
show a loss of verbal skills. These can cover a wide range of disorders: loss of
naming skills, problems in grammar, loss of oral language, inability to under-
stand language, disorders of reading, reading comprehension, writing, spelling,
or arithmetic, word substitution. verbal confusion, fluent aphasias. dysfluent
aphasia, and any other symptom complex seen with verbal skills.
Disorders may also be nonverbal in nature. This can include difficulty
drawing simple or complex figures, difficulty with spatial relationships, prob-
lems in map reading and finding one's way around new or even familiar neigh-
borhoods, difficulty in recognizing or maintaining sequences, problems with
facial recognition, figure or background distortions. difficulties in telling time,
problems in recognizing the passage of time, difficulty in recognizing nonver-
bal sounds (e.g., the sound of a train), and problems in expressing or recogniz-
ing emotions.
Other disorders may include inflexibility, an inability to solve problems,
poor judgment, impulsivity. poor attention and concentration, inappropriate-
ness, aggressiveness, irritability, improper social behavior, and hyper- or hypo-
emotionality. Across disorders. any problem which can be caused by brain
damage will be seen in some cases of dementia.
Laboratory Findings
Each type of dementia is characterized by specific laboratory findings. al-

though there is at present only a mild to moderate relationship between the lab-
oratory findings and the behavioral symptoms as outlined above. In many
cases, absolute neuropathological identification requires an autopsy. Even with
a typical autopsy exact identification of the presence of a dementing disorder or
a specific dementing disorder is questionable. Alafuzoff (1992; Alafuzoff,
Ronnberg, & Asikainen-Gustafsson, 1991) found a lack of correspondence be-
tween neuropathological findings and clinical findings of dementia that they
blamed partially on autopsy techniques.
TYPES OF DEMENTIA
There are several systems for classifying the dementias. However, since
DSM-IV remains the basic nomenclature in the United States, we use that clas-
sification system to structure this chapter.
Alzheimer's Disease
Alzheimer's disease (AD) represents the most common form of dementia.

Skoog and colleagues (1993) identified 43% of their general dementia sample
with this disorder. Precise numbers are difficult because of the problems in di-
agnosis without a detailed autopsy. Alzheimer's disease is characterized by se-
vere memory disorders, loss of smell, and a wide variety of cognitive problems.
Onset may be at a relatively young age (less than 50 years) or at any time there-
after. The progress of the disease may be very short or may last over a decade
from the time the disorder is first diagnosed.
Alafuzoff (1992) describes the pathological changes in AD as primarily mi-
croscopic lesions in the brain including neurotic plaques and neurofibrillary
changes (tangles) within clusters of nerve cells. These are accompanied by se-
lective loss of neurons, neuronal atrophy, and the accumulations of granules be-
tween cell bodies. The plaques have a central amyloid core and other distinct
neuropathological characteristics.
In his review, Edwards (1993) suggested that the most serious problems in
AD are found in the temporal lobe in the hippocampus and the amygdala. Al-
though some theorists have suggested that the problems in AD are related only to
changes in cholinergic pathways, Holttum and Gershon (1992) rejected a unitary
cholinergic theory. They suggested that approaches that transcend single neuro-
transmitter systems are necessary to explain the disorder. Some research demon-
strates that AD may be related to a genetic predisposition (e.g., Jarvik, 1992).
The definitive diagnosis for AD must come from neuropathological evi-
dence. However, such evidence is rarely available until after the death of the pa-
tient. Thus, diagnosis often comes through ruling out other causes, such as
vascular dementia, rather than from a definitive constellation of symptoms that
differentiates AD from other dementias. To be considered AD, there must be a
gradual onset of symptoms without evidence of focal damage associated with
vascular dementia or the specific features associated with other dementias. In
addition, AD tends to show more symptoms over time associated with the tem-
poroparietal areas of the brain (e.g., language problems, visual spatial difficul-
ties, naming problems) than do other gradual dementias such as Pick's disease.
Because the presentation of AD may vary quite widely in clinical samples,
there has been speculation that there may be subtypes of the disorder or even
different diseases being grouped together erroneously. Although some misclas-
sification certainly takes place because of the unavailability of a definitive diag-
nostic procedure, at present there is no evidence of different subtypes of AD but
rather differences in presentation which depend on such factors as premorbid
status, age at onset, and the overall rate of degeneration (Kurz, Haupt, Poll-
mann, & Romero, 1992).
Vascular Dementia
Along with Alzheimer's, this is the most common cause of dementia cur-
rently identified. Vascular dementias are characterized by the presence of cere-
brovascular disease. Vascular dementia can arise from one major infarction,
Dementia 117
occlusion, cerebral hemorrhage, or from a series of vascular problems that may

develop over many years. The initial symptoms vary considerably depending
on the location of the vascular lesion and other related neurological factors. Un-
like cases of AD, individuals with vascular dementia will often show focal neu-
rological signs and clear areas of injury on MR! or CT scan. However, in milder
cases, such tests may appear normal especially when it is the result of many
small focal injuries rather than one or more larger injuries.
The wide variety of presentations possible make clear criteria difficult. Ro-
man and colleagues (1993) developed a series of research diagnostic criteria for
this disorder. They identified a series of different lesions which may be associ-
ated with the problem. Most common is multi-infarct dementia, in which there
are multiple large vessel infarcts involving both cortical and subcortical areas.
MR! and CT scans are typically quite abnormal in this subtype. Multi-infarct
dementia may also arise from a series of small strokes that may be mistaken for
Transient Ischemic Attacks (TIA) that leave no residual deficits. In these cases,
the amount of damage done each time is slight and difficult to see, but the ac-
cumulating damage over time leads to dementia.
A second type of dementia arises from single infarcts which produce small,
localized damage in an important part of the brain and may produce well-
defined and striking forms of dementia. For example. infarcts within the left
angular gyrus may produce a fluent aphasia in which the motor production of
words is maintained, but their meaning or understanding may be lost. The most
extreme forms of this are jargon aphasia in which the person speaks fluently but
makes no sense whatsoever, or receptive aphasia in which the person is unable
to understand spoken or written communications.
Infarcts of the posterior cerebral artery may present with visual field loss,
visual hallucinations, agitation, confusion, and memory loss. Injuries to the
anterior cerebral artery may result in a loss of initiative, inability to locate mem-
ories, agitation, irritability, and emotional liability. Middle cerebral artery in-
farcts can result in aphasia, irritability, spatial losses, paranoia, confusion, and
impairment in all basic achievement skills. Lesions in subcortical areas may re-
sult in thalamic dementia, with severe memory loss and confusion, or disorders
in which new memories are completely lost while leaving old memories intact
(bilateral hippocampal lesions).
Another major subtype is small vessel disease in which blood flow is main-
tained within the large vessels but not within the smaller vessels. This may
cause subcortical or cortical symptoms in which onset may appear to be grad-
ual and more like AD than the more sudden or clearly stepwise deficits seen in
other forms of vascular dementia. This disorder may cause small lacunar in-
farcts in the brain which can be detected on MR!. However, the presence of
such small areas of dysfunction do not always correlate with behavioral or cog-
nitive impairment. The deficits from this disorder may include personality
change, difficulty with complex executive tasks (also as seen in Pick's disease),
and diffuse memory problems. More focal and definitive cognitive signs, as
seen in other forms of vascular dementia, are rare in this disorder.
Another important form of vascular dementia arises from cerebral hypoxic
events. These result in a loss of oxygen to the brain secondary to the inability of
the heart and lungs to provide enough oxygen to the brain, or the inability of the
oxygen to reach areas of the brain due to edema or other restrictive factors. It is
well known that brain damage arises quickly from a complete loss of oxygen to
the brain (anoxia); partial losses of oxygen (hypoxia) can also cause damage al-
though over longer and more indeterminate periods of time. These deficits tend
to be diffuse and less focal, sometimes mimicking small vessel disease as well
as dementias caused by substance abuse and poisoning.
Diagnosis of vascular dementia may be clear from CT scan or MRI studies.
In addition, measures of blood flow may be used to show areas of the brain with
little or no circulation even when the areas look normal on tests that show only
structure. The presence of clearly abnormal findings on these tests can usually
be considered diagnostic if the required memory and cognitive disorders can be
demonstrated with neuropsychological tests. As noted earlier, routine neuro-
logical testing may also show clear signs of a possible disorder.
It should be noted that the various forms of vascular dementia can occur si-
multaneously in one person, or in conjunction with other forms of dementia.
Dementia Due to General Medical Condition
In DSM-IV, this diagnosis includes a wide range of subtypes in which the

symptoms of a dementia can be demonstrated along with clear medical and his-
torical information that the dementia is related to the medical condition. Each
of these disorders has its own clear diagnostic requirements based on history,
symptoms, and laboratory findings.
HIV
This is a relatively new and increasingly diagnosed form of dementia seen
in both younger and older populations. HIV (human immunodeficiency virus)
is transmitted between individuals primarily as the result of sexual contact or
other forms of bodily fluid exchange including the use of contaminated needles
or from contaminated blood. HIV attacks the human immune system, and is
found throughout the body. Berg, Franzen, and Wedding (1994) reported that
upon autopsy, pathological involvement of the brain is seen in more than 75%
of all patients. In addition, the virus's attack on the immune system allows nu-
merous opportunistic infections to attack the body, including the brain. These
factors may result in a subcortical dementia characterized by memory loss,
confusion, personality change, and impairment in higher cortical functions. Di-
agnosis depends on the demonstration of an HIV infection followed by the de-
velopment of dementia-like symptoms.
Head 1rauma
This is a more common cause of dementia than has been recognized in both
elderly and young populations. The elderly are particularly susceptible to the
effects of falls and automobile accidents because of decreased resiliency of the
brain in this age group. However, this cause is often ignored because the in-
juries are not reported, appear not to be serious, or the symptoms are ascribed
Dementia 119
to normal aging by individuals unfamiliar with the client's premorbid status or

by family in denial.
The symptoms in milder cases are difficult to identify because of the wide
range of normal variation in the elderly. The most common results of mild to
moderate head injury are a mild memory disorder of new memory along with
mild impairment in higher-level executive functions (Golden, Zillmer. & Spiers,
1992). Emotional liability may also be seen. The memory impairment is often
misdiagnosed as just normal forgetting associated with aging, and the impairment
in executive function is clear only with novel stimuli or highly stressful or com-
plex situations that are unfamiliar. In an individual who is retired, such situations
may be rare. In addition, elderly clients are less likely to be in situations that they
find unfamiliar. When they are, deficits are again ascribed to normal aging.
As a result, deficits may pass unnoticed for substantial periods of time un-
til later noted during a crisis. At that time, the role of the head injury may be
missed, yielding a misdiagnosis of another type of dementia (usually AD or dif-
fuse vascular dementia) or even leading to a diagnosis of depression or schizo-
phrenia despite the lack of premorbid history of such disorders.
Neurodiagnostic tests are rarely helpful in these cases, even when con-
ducted immediately after the injury. Unless there is bleeding or other significant
vascular events secondary to the head injury, CT and MRI may be nonsignificant
and measures of blood flow will be equivocal at best in many cases. Neurologi-
cal examinations may be normal. Diagnosis is most often established by a well-
developed history rather than more elaborate diagnostic devices.
Parkinson's Disease
This disease, the symptoms of which have been recognized for centuries,
was first embodied as a disease entity by the work of James Parkinson in 1817
(Golden et al., 1992). The disease occurs in less than 1 % of the population.
Parkinson's disease is a progressive disorder marked primarily by motor symp-
toms: tremor, rigidity, postural instability, and bradykinesia. Dementia is not
always associated with the disease, but is seen in more advanced stages, with
estimates of incidence ranging from 0% to 81 % in different studies (Biggins et
al., 1992). In their own longitudinal study, Biggins and colleagues (1992) esti-
mated an incidence of 19%. It may occur in as much as 1 % of the elderly pop-
ulation. Parkinson's disease is considered a disorder of the basal ganglia that
usually begins in middle age or later. The symptoms are related to a disturbance
of dopaminergic activity in these areas.
Parkinson's disease may be idiopathic or may arise from head injury, vas-
cular disease, or other disorders of the brain that affect the appropriate parts of
the brain. Parkinson-like symptoms may develop from certain antipsychotic
medications. The onset is slow in idiopathic Parkinson's disease.
Individuals with Parkinson's will initially present without any cognitive
symptoms, but will show a resting tremor, rigidity, and involuntary movements.
Voluntary movements may be slow. The tremors usually start distally. There
may be disorders of posture, motor disturbance of speech, and motor problems
with walking. Facial expression may be lost, resulting in a rigid, "masked" ap-
pearance. Repetitive movements will be slowed.
When cognitive symptoms develop, they appear more diffuse, with im-
pairment of memory and executive functions. On many tests, however, general
motor and motor speech impairment can lead to a misdiagnosis of cognitive
dysfunction. For example, low performance IQs reported on the Wechsler Adult
Intelligence Scale may be the result simply of motor impairment (see Marsden
& Fahn, 1987). Some deficits, however, can be recognized independent of mo-
tor and speed issues but these are not clearly typical of the disease (Golden et
a1., 1992). Diagnosis of dementia in Parkinson's arises from confirmation ofthe
symptoms through history and neurological examination, followed by confir-
mation of dementia where no other likely cause is present.
Huntington's Disease
Huntington's disease is the classical prototype of a dementing disorder clearly
related to genetic issues. The disease is a progressive, degenerative disorder that
clearly runs in families. It is transmitted through a single autosomal dominant
gene on chromosome four. The onset of symptoms is usually after age 30, but may
occur at any time in the life span including well past age 60 (Golden et al., 1992).
Early symptoms may reflect changes in personality: irritability, mood
change, depression, anxiety, and hypersexuality. Movement disorders charac-
terized by stereotyped atypical chorioid movements then develop. Dementing
symptoms including memory problems, executive problems, and eventually
problems throughout the brain accompany this degeneration. Frank psychosis
may develop. The progression of the disease can be closely followed by perfor-
mance on neuropsychological tests.
Diagnosis can be established through history, genetic testing, and neuro-
logical and neuropsychological examination. The disease presentation is rather
clear as it progresses, and it can usually be easily distinguished from other
forms of dementia.
Pick's Disease
First described by Arnold Pick in 1892, Pick's disease is a degenerative dis-
ease of the brain focused in the anterior fronto-temporal areas of the brain. The
disease is progressive and irreversible. This disorder results in a wide variety of
symptoms ranging from mood changes, irritability, and instability, to a lack of
flexibility, planning, new memory, and judgment.
The neuropathology of the disorder is characterized by the presence of
Pick's Bodies as opposed to the tangles seen in Alzheimer's disease. This is ac-
companied by clear atrophy of the frontal and temporal lobes which can be
seen on autopsy as well as on MRI or CT scan. In summarizing the literature,
Cummings and Benson (1992) described three stages for the development of the
disease: loss of higher executive functions characterized by impulsivity, irri-
tability, and loss of social skills; a second stage characterized by verbal deficits,
aphasia, and deterioration of judgment; and the final third stage characterized
by a disintegration of behavior across many modalities and skills.
The behavior of Pick's patients may be quite bizarre due to the loss of social
skills, judgment, and social awareness. This can include roaming behavior,
Dementia 121
poor hygiene, urination in public, disinhibition, inappropriate comments,

childlike behavior, hyper- or hypo-orality, hypersexuality, hyperaggressiveness,
apathy, loss of initiative, echolalia, perseveration, anomia, compulsive or ritu-
alistic behavior, lying, general criminal behavior, lack of insight, psychotic-like
behavior, and mood swings (Golden, Osmon, Moses, & Berg, 1981; Jung &
Solomon, 1993; Mendez, Selwood, Mastri, & Frey, 1993; Miller et al., 1991).
The diagnostic dilemma in this disorder is that final diagnosis requires an
autopsy as in Alzheimer's disease. In later stages, AD and Pick's may seem be-
haviorally similar and this can lead to misdiagnosis in the absence of a good
history. In some cases, CT, MRI, and SPECT will demonstrate the clear anterior
nature of the atrophy which would clearly lead to a suspicion of the disorder.
This is not true in all cases, however, and autopsy may lead to reversal ofthe di-
agnosis. About 10% of all dementias are likely to be cases of Pick's disease.
Creutzfeldt-Jakob Disease
Creutzfeldt-Jakob disease is a rare degenerative disorder that is inevitably
fatal and that can be transmitted from person to person. The disorder typically
appears at about age 60, but can occur at any age. The disorder was first de-
scribed by Creutzfeldt and Jakob in the second decade of the twentieth century
(Ball, 1980; Beck & Daniel, 1987; Brown, 1989; Jones, Hedley-White, & Fried-
berg, 1985).
The disease follows a clear course. During the prodromal phase, the client
has mild, nonspecific physical symptoms along with feelings of fatigue and
concentration problems. Subsequently, a full cortical dementia develops with
symptoms of aphasia, executive dysfunction, delusions, hallucinations and
general intellectual deterioration. Motor symptoms and abnormalities also de-
velop during this time. The last stage is characterized by stupor, multiple phys-
ical problems, and eventually death. The neuropathological sign of the disease
is the spongiform appearance of the cerebral cortex which can be identified on
autopsy.
The disease can be divided into familial and transmissible forms. There are
several variants of the disease that have been identified but they all have the
same fatal, rapidly degenerative course. Definitive diagnosis is difficult without
biopsy, and in many cases is not even considered because the disease is so rare
(1 incidence per 1 million people). Familial history or preexisting trauma or
neurological disease may increase the likelihood of the disease.
Other
This category includes a wide variety of medical disorders that may have a
primary or secondary effect on the function of the brain. Several of these are rel-
atively common in elderly populations and must be considered in any case of
dementia.
One of the most common of these disorders are tumors. For our purposes, tu-
mors can roughly be divided into three categories: extrinsic, intrinsic, and
metastatic (Golden et a1., 1992). Extrinsic tumors are those that are inside the
skull but do not invade the tissue of the brain itself. Rather, these tumors cause
problems by increasing in size, compressing brain tissue, and increasing in-

tracranial pressure. The symptoms of increased intracranial pressure include
headaches, nausea, incontinence, balance problems, memory problems, and dif-
ficulty with attention and concentration. More localized symptoms may occur de-
pending on exactly which tissue in the brain is compressed (although this may
not always reflect the physical location ofthe tumor). When extrinsic tumors are
slow growing, they may show little effect. In the elderly, in whom brain atrophy
is common as a result of normal aging, the tumor may have additional space in
which to grow before causing any visible symptoms. Some extrinsic tumors are
first discovered at autopsy without any clinical correlations before death.
Intrinsic tumors are those that invade and destroy healthy brain tissue.
These tumors primarily differ (for our purposes) on the basis of speed of devel-
opment from slow to very fast. The slowest tumors may cause few problems as
the brain is able to adjust to the slow loss of tissue with appropriate behavioral
adaptations, although problems may show after enough tissue has been com-
promised. Faster-growing tumors, however, may cause both highly localized ef-
fects (as seen in the localized vascular dementias) as well as more general
effects from increased intracranial pressure. These disorders can develop quite
quickly and may even be mistaken for a vascular disorder. All ofthe forms oftu-
mors can be easily identified in most cases by MRI or CT scan.
The third form of tumors are metastatic tumors. These are usually tumors
secondary to various forms of cancer, most often from lung or breast cancer al-
though any form of cancer can metastasize to the brain. Metastatic tumors must
be considered in any individual with a history of cancer who shows a quick on-
set of dementia-like symptoms, even years after the original cancer has been
treated. The symptoms are generally highly focal and severe, and again may be
mistaken in some cases for vascular dementia.
Another important disorder in the elderly is normal pressure hydro-
cephalus. This disorder differs from the form of hydrocephalus seen in younger
individuals. In younger cases, hydrocephalus is the result of pressure within
the ventricular system increasing because of blockage or a failure to reabsorb
CSF fluid. In normal pressure hydrocephalus, the pressure within the ventricu-
lar system remains normal. What changes is the ability of the brain tissue to re-
sist that pressure. Instead of "pushing back" on the ventricles, the brain tissue
collapses and compresses. This results in symptoms similar to increased pres-
sure or edema as discussed earlier.
The presence of enlarged ventricles can be easily diagnosed through CT
scan or MRI, but the presence of enlarged ventricles is not diagnostic of normal
pressure hydrocephalus. In many normal elderly, we see normal atrophy of the
brain in which the brain shrinks on its own rather than through compression. In
some of these cases, the shrinkage is due to a disease process such as AD, but in
other cases it is normal. The enlargement of the ventricles is simply a "space
filling" response rather than a compression of the brain tissue. In these circum-
stances, the ventricular enlargement has nothing to do with any symptoms
shown by the patient.
Thus, normal pressure hydrocephalus can be diagnosed only in cases where
the ventricular enlargement is compressing the brain. This requires both identi-
Dementia 123
fying the generalized symptoms of the disorder neurologically, cognitively, and

behaviorally, and ruling out any other causes for the observed brain atrophy.
A third possible cause of dementia within this group are subdural hema-
tomas. A hematoma is a "sack" of blood between layers of the meninges that
occurs as a result of bleeding into the subdural space. These can occur spon-
taneously when a vessel breaks due to arteriosclerosis, a defect in the vessel, or
as a result of a head trauma. In the elderly, such a head trauma may be very
mild and may have occurred several weeks prior to the development of symp-
toms. Traumas such as hitting one's head on a door or a mild fall can lead to the
onset of the hematoma.
The effects of the hematoma will depend on the rate at which the hema-
toma grows, the amount of space available in the brain, and the ability of the
brain to reabsorb the hematoma. In some cases, the hematoma may pass with-
out notice. In other cases, symptoms of a space occupying lesion will develop
as is seen in extrinsic tumors and normal pressure hydrocephalus. Untreated,
the dementia can become quite severe and the hematoma can become life
threatening. In some cases, sustained elevations in intracranial pressure can
restrict blood flow and cause a permanent dementia via sustained hypoxia. As
in other space occupying lesions, the clue to diagnosis is the development,
slowly or quickly, of headaches, confusion, incontinence, balance, and mem-
ory problems.
Nutritional disorders are also a common cause of dementia in the elderly.
This may result from changes in smell and taste that restrict the enjoyment of
food, leading to a tendency either to eat less than needed or to restrict diets to a
very few foods (e.g., a patient who would only eat chocolate pudding, from a
certain manufacturer, and coffee). Such restrictions may also arise from eco-
nomic or physical limitations that inhibit access to a wide variety of foods, or
from the presence of dental or gastrointestinal problems that interfere with con-
suming or absorbing foods. In all of these cases, the eventual outcome is a se-
vere nutritional deficiency (e.g., niacin or vitamin B12 ) that leads to generalized
confusion and dementia. Such deficiencies may also be the side effects of cer-
tain medications or combinations of medications.
The elderly may also demonstrate a variety of demyelinating diseases such
as multiple sclerosis (MS) or Lou Gehrig's disease. The latter are two well-
known examples of a wide variety of demyelinating diseases in which the pri-
mary initial symptoms are sensory or motor in nature. As these diseases
progress, however, problems with memory, attention, concentration, and exec-
utive and personality functions may develop. Dementia is by no means an in-
evitable outcome of these disorders, but it is seen in more severe forms of the
disease. As with Parkinson's disease, it is important not to misinterpret motor
and sensory problems as cognitive problems.
Infections of various kinds may also lead to dementia. These include menin-
gitis and encephalitis, which may arise secondary to other viral and infectious
diseases in individuals who are otherwise weak or have immunological impair-
ment. In some cases, brain abscesses will develop which destroy specific areas
of the brain. In the elderly, these disorders can result in permanent nonprogres-
sive dementias characterized by memory loss, attentionalloss, and disorders of
executive skills. A clear history is often necessary to identify this etiology. In

such cases, the onset of symptoms can usually be traced to the development of
the illness, with the resolution of the illness leading to only partial remission of
the symptoms. This is sometimes missed as residual symptoms are seen as signs
of continuing recovery rather than as signs of permanent injury.
A final set of causes arise from treatment. These can be, for example,from
the effects of general anesthesia in the elderly or the effects of chemotherapy or
radiation therapy for cancer. In some cases, these disorders are correctly clas-
sified as deliriums; however, in many -cases there may be residual symptoms
that do not recover even after the cessation of the treatment. If the memory and
cognitive symptoms are present, then these would also be properly labeled as
dementias.
Substance-Induced Persisting Dementia
This class of dementia is in general less important in the elderly as onset

is generally before age 50. The substance involved may be alcohol, inhalants,
hypnotics, sedatives, anticonvulsants, heroin. cocaine. LSD, and so on. The
most important substance issues in the elderly are the long-term effects of alco-
hol along with the effects of prescription medication.
Perhaps the best known of these disorders in the elderly is Korsakoff's syn-
drome secondary to chronic use of alcohol, the most abused substance within
the elderly population. Many years of heavy drinking is necessary for the onset
of this disorder, and the onset is often accompanied by other problems such as
vitamin deficiencies and failure of the liver or kidneys. Berman (1990) esti-
mated that alcoholic dementia may represent as much as 10% of all dementias
although this figure is not universally accepted. This syndrome is characterized
by extreme memory problems along with confabulation to fill in memory
losses. Memory loss often extends back to when the person began heavy drink-
ing although the presence of confabulation may not make this clear upon cur-
sory examination. New memory formation is almost nonexistent (Brandt &
Butters, 1986). Other symptoms may include problems with higher-level exec-
utive functions and visual spatial functions (Jacobson, Acker, & Lishman, 1990).
Although improved nutrition and medical care may decrease symptoms, the
likelihood ofrecovery remains low (Parsons & Nixon, 1993).
Another form of substance-induced dementia in the elderly is the effects
of prescription medication. These medications may have relatively benign ef-
fects in younger individuals, but some elderly show significant cognitive reac-
tions to extended pain medication, hypnotics, antipsychotics, antidepressives,
anxiolitics and other medications either alone or in combination. Some of
these effects may be temporary, causing delirium, but other effects may be per-
manent even though the length of time on medication was limited. In more
chronic use, longer-lasting effects may be noted. In some cases, the effects of
the medication or combination of medications is idiopathic and unexpected;
others are the result of improper monitoring of the greater effects of medication
in the elderly.
Dementia 125
Other Categories of Dementia
The category of "dementia due to multiple etiologies" is used when there is

more than one documented etiology for the dementia. This is commonly appro-
priate in the elderly as several different problems may lead to an individual pre-
sentation of dementia. The category of "Dementia NOS" is used when no cause
can be established although the diagnostic symptoms of dementia are present.
DIAGNOSIS
The diagnosis of dementia takes place in several steps. First, there is a need
to establish the presence of symptoms which may initially suggest the possibil-
ity of a dementia. Second, there is the need to establish that a dementia clearly
exists. The third stage involves establishing a specific diagnostic type, which
may in turn allow for treatment or prognostic plans. In each phase, information
is gained from several specific sources: (1) history; (2) evaluation of activities of
daily living; (3) screening examinations; (4) neurological, neuroradiological,
and medical examinations; and (5) neuropsychological testing.
History
History is an extremely important component of any evaluation of demen-

tia, but one which is often slighted in favor of questionnaires, screening tests,
and neuroradiological findings. However, history is necessary to establish that
the individual was once functioning at higher levels, as the presence of any of
the disorders discussed in this chapter assumes that the person was once func-
tioning at a higher leveL Without a well-taken history, such decline may not be
recognized, especially in otherwise higher-functioning individuals. Lower levels
of initial function, due to education, basic IQ, or background, may be misinter-
preted as signs of dementia. There is a bias to underdiagnose these disorders in
highly intelligent individuals and to overdiagnose in minorities and those with
lower education.
Any history should extend beyond a basic questionnaire, as families may
not recognize what is important or may be in denial. They may also fail to under-
stand the meaning of specific questions.
Histories should be oriented toward gathering basic concrete behavioral ob-
servations rather than generalities or conclusions. Thus, a complaint of memory
problems should be broken down into specific acts: "he loses his key," "he can't
remember the route to get to work," "he leaves the house and can't find his way
home," and other such basic complaints. In addition, it is important to generate
information about the frequency of the behavior, the situation that accompanies
the behavior, and the frequency of the behavior in the past. If possible, it is im-
portant to identify a timeline that indicates when the behavior was absent and
the speed and degree at which it developed over time. This should be done for
each abnormal or changed behavior, whether this involves medical symptoms
(such as headaches or nausea), cognitive changes (memory problems or prob-

lems with speech or attention), or personality change (irritability, depression,
apathy, aggression. hallucinations, delusions).
History can be used as basic evidence for the existence of a dementia
or an alternative diagnosis such as depression. Indeed, although the absence
of a clear history does not rule out the diagnosis, a well-taken history with
proper evidence clearly establishes that a problem exists and generally ob-
viates the need for screening tests that have a high rate of misdiagnosis. In
many of the dementing disorders, history (along with clear-cut evidence of a
decline in functioning) is indeed the best diagnostic indicator in the absence
of an autopsy.
This is especially important in such disorders as AD, Pick's disease, Kor-
sakoff's disease, and other dementias in which there are no clear diagnostic
tests that can confirm the disease process itself (although many that can iden-
tity the presence of the memory and other behavioral or personality character-
istics of the disease). Vascular dementia can be recognized by its stepwise
development of symptoms, as opposed to the more continuously developing
disorders such as AD or Pick's disease. Korsakoff's disorder requires a clear his-
tory of alcoholism, and histories of smoking, cancer, liver disease, and others
can be major markers in the diagnosis of a specific dementia.
History is important because of the overlap between the various forms of
dementia in terms of symptoms and course of development. For example, some
individuals with AD may have had alcohol histories simply because of the
prevalence of alcoholism in our communities. It is easy to settle on alcohol as
the one explanation without thoroughly investigating all of the alternative pos-
sibilities. When the differential is between two untreatable forms of dementia,
this is not so serious an issue. However, when the differential involves treatable
as well as untreatable alternatives, delay in getting an accurate diagnosis can be
extremely dangerous to the client.
When there are alternative interpretations, histories should be gathered to
indicate the possible alternatives. While this is not always definitive, good his-
tories can clearly indicate what medical tests or further information is neces-
sary to further refine the diagnostic procedure.
Activities of Daily Living
This is another extremely important part of the diagnosis. Many will come
in with complaints that are subjective and hard to pin down, but focusing on
ADLs offers both a more concrete example of the impact of the problems and an
assessment of their severity in a real-life setting. This is quite important in as-
sessing the likelihood of dementia in marginal cases and in treatment and long-
term planning.
Many scales for ADL activity exist, but most are general and oriented to-
ward acute, quick-onset disorders. These are less sensitive to the early stages
of the chronic progressive disorders. Although new scales which may be more
sensitive and more useful are being developed, they are as yet not well re-
searched or ready for general use.
Dementia 127
Thus, evaluations remain at present more subjective than objective. The

focus of an evaluation should not be on the level of function of the individual
in a given area (which is relatively difficult), but on change over the past year
or other appropriate time period. Such investigations should obtain the report
of the patient and someone close to the patient. Patient reports are often in-
adequate and may overestimate or underestimate the patient's actual level of
function. The report of a close individual may also be biased, but separate de-
terminations can identify areas of disagreement that may require more detailed
evaluation.
ADL evaluation should cover at least the following areas:
Basic Care
Basic care includes hygiene, dressing, bathing, eating, and drinking. These
areas are those most often covered in traditional ADL scales. Impairment in
these areas suggests a severe disorder, an acute disorder, or a relatively pro-
gressed chronic disorder.
Social Relationships
Social relationships include the ability to interact with groups of people,
handle stressful or complex relationships, act in an appropriate manner, resist
impulsive behavior, act in a tactful manner, and maintain preexisting relation-
ships. People who know the individual well at home or work can often con-
tribute important observations.
Household Chores
Household chores include such tasks as cleaning, laundry, food prepara-
tion, gardening, and care of personal goods. These are important areas related to
an individual's ability to function independently and are good markers of
changes in cognitive status.
Financial Responsibilities
Financial responsibilities include paying bills, investing, budgeting, mar-
keting, handling credit and credit cards, and other financial transactions. These
areas are relatively complex and require active and continual involvement.
Deficits in this area can range from simple mathematical errors, which become
more common, to a loss of the ability to see the long-term consequences of spe-
cific behaviors or to understand what is being done at all.
Work Responsibilities
Work responsibilities vary depending on whether the person is employed
or retired, and on the nature of the job if the client is employed. In early de-
mentia, coworkers and superiors may notice a decrease in the quality of actions
taken, a lessening of the ability to deal with stress and crisis situations, and a
lessening of planning activities. Behavior may become more impulsive and less
socially appropriate with coworkers as well as customers or clients. Decision
making and responsible behavior will be impaired. This is often ignored or ex-
plained as temporary but needs careful investigation in identifying early onset
of dementia.
Problem-Solving in Daily Life

Areas may include household repairs, responsibilities in community orga-
nizations, family obligations, and other areas where problem-solving skills are
expected. Early deficits may again show up in these areas and may include
withdrawal from activities to avoid making errors (although the client may not
state this).
Driving Skills
This area includes the motor and perceptual act of driving as well as the
more cognitive acts of planning and finding one's way in unfamiliar areas. Ba-
sic driving skills will often remain stable in early to moderate dementias, but
problems will be seen in dealing with novel or complex driving situations and
in spatial skills related to map reading. Motor or perceptual problems seen in
some specific disorders may also appear as well.
Motor Skills
Motor skills include the necessary coordination, balance, timing, and cog-
nitive skills for walking, running, stair climbing and other physical activities.
These are common in disorders like Parkinson's disease, vascular dementias,
demyelinating disorders, and other dementias that affect the motor system.
Early symptoms may be reflected only in slowness. There may be a loss in the
ability to continue athletic activities at the level previous to the decline.
Recreational Activities
Recreational activities include athletic activities, card games, dancing,
movies, reading, hobbies and all other activities done for enjoyment. Individu-
als may show a loss of interest in activities without clear-cut evidence of de-
pression. This loss of interest is usually related to an inability to perform the
activities at the previous level of competence and an attempt to avoid embar-
rassment. Loss of interest may also arise from an inability to gain pleasure from
the activity due to a recognition of the loss of skills, attentional and concentra-
tion problems, or other cognitive factors. It is important to explore this area to
differentiate this change from the loss of interest that accompanies depression.
Planning and Evaluation in All Aspects of Behavior

One of the major activities which distinguishes adults from children is the
ability to plan and anticipate the consequences of behavior and to learn from
Dementia 129
previous experience with a situation. This, again, may be lost early in dement-
ing disorders with the individual becoming fixated on one approach without
learning from consequences or being able to recognize what consequences are
likely. Such individuals become more focused on day-to-day or hour-to-hour
gains without seeing the whole picture.
Perseveration
Perseveration refers to both inflexibility and the tendency to repeat oneself.
In memory disorders, this may involve forgetting that one has asked or done
something, leading to repetition of the behavior. In other cases, clients may de-
velop rituals to avoid having to make decisions or be placed at a disadvantage.
In more serious cases, the client may repeat single phrases (e.g., "Kentucky
Fried Chicken" or "OK. OK. ").
Evaluation of these active behaviors adds a substantial amount of informa-
tion to the traditional mental health or medical history. Combined with the re-
mainder of the data, information about these behaviors adds considerably to
diagnosis and treatment planning.
Screening Examinations
This is an area that has received an inordinate amount of attention in the

literature. Such examinations appear to offer much to users: fast evaluation and
classification of clients that can be performed even by nonprofessionals. They
are often used in place of a detailed history or ADL evaluation, or as a method
of justifying or not justifying ordering of neuroradiological or neuropsycholog-
ical testing. They can be used for quick objective classification of clients in re-
search studies at minimal cost.
Such tests have significant disadvantages in the diagnosis of an individual
when used alone. First, all have significant error rates especially in the mild or
early dementias. They do best in identifying the presence of moderate to severe
dementia. The difficulty here is that moderate to advanced dementia is fairly
easy to recognize without such testing. In clinical work, it is the mild cases or
beginning cases that present problems. When one considers issues of base rates,
false positives, and false negatives within the mild population, many individ-
ual diagnostic errors will be made that have potentially significant impact on
the individual client.
The second problem is that these tests sample only a small number of the
areas that can be affected in dementia, and none effectively sample such func-
tions as personality changes, impulsivity, and loss of social skills. Even if one
assumes that the tests detect everything in the areas they measure, many other
areas are ignored. Thus, a given test might adequately sample for a given form
of dementia, but not for others. Unfortunately, these tests are interpreted as
measuring for all forms of dementia.
Despite these limitations, researchers and clinicians have focused on their
use. Probably the most frequently used of these examinations has been the
Mini-Mental State Examination (MMSE) (Folstein, Folstein, & McHugh, 1975).
Some studies have reported excellent results in general and patient popula-
tions between normal and demented subjects (Anthony, LeResche, Niaz, von
Korff, & Folstein, 1982; Ashford et aI., 1992; Van der Cammen, Van Harskamp,
Stronks, Passchier, & Schudel, 1992; Galasko et aI., 1990; Kay et aI., 1985).
However, accuracy rates generally remain under 90% and substantially less in
some populations.
Fratiglioni, Grut, Forsell, Viitanen, and Winblad (1992) found that while
significant results could be found for the MMSE, significant and serious errors
were still made. Sabe, Jason, Juejati, Leiguarda, and Starkstein (1993) found that
when normals were compared to mild (but already identified) dementia cases,
no normals were misidentified; however, only 55% of the demented subjects
were correctly identified. Fields, Fulop, Sachs. Strain and Fillit (1992) found
the MMSE better than the Neurobehavioral Cognitive Status Examination
(NCSE), but again found accuracy rates (as measured against a psychiatric opin-
ion) to be low.
Many other tests have been suggested in the literature but none has been
proven reliably superior to the MMSE or researched as well (e.g., Copeland,
Kelleher, Kellett, Gourlay, & Gurland, 1976; Everhuis, 1992; Gurland, Kurian-
sky, Sharpe, Simon, & Stiller, 1977; Overall & Schaltenbrand, 1992; Roth, Tym,
Mountjoy, Huppert. & Hendrie, 1986; Zaudig, 1992; Zaudig, Mittelhammer,
Hiller, Pauls, & Thora, 1991).
Overall, these results suggest that screening tests can be used, but not as the
only or most important criteria for determining the presence of dementia. They
must be regarded within their individual limitations as only one source of in-
formation along with other detailed information from the other domains iden-
tified in this section These tests may also be useful as longitudinal indicators in
changes in status over time rather than diagnosis per se.
Radiological and Medical Evaluations
These are essential aspects of any evaluation of dementia. Behavioral and

cognitive symptoms, along with historical and ADL information, may be used
to define the presence of dementia, but they can only suggest the etiology of the
disorder. While establishing the absolute cause of a dementia is not always pos-
sible without an autopsy, it is absolutely necessary that medical examinations
rule out the many fully or partially treatable forms of dementia in order to en-
sure the best possible medical care or the longest maintenance of the client's
level of function.
This area includes a complete medical examination including appropriate
tests for diabetes, thyroid disorders, kidney disorders, liver disorders, heart dis-
orders, lung disorders, cancers of all kinds, blood disorders, endocrine disorders,
poisoning, and other medical correlates of dementia. The specific tests con-
ducted depend on the patient's symptom presentation, history, and other rele-
vant factors. Such an examination needs to be thorough and complete before
concluding that none of these factors are relevant to the patient's symptoms.
A complete neurological examination is useful for detecting gross distor-
tions in mental status and the presence of any localized or diffuse neurological
Dementia 131
signs. Particular care is necessary for the identification of signs of increased

intracerebral pressure, which may suggest tumors, edema, hydrocephalus, he-
matoma, and other disorders, and strong localizing signs, which may suggest
vascular lesions, certain localized tumors, or focal areas of confusion. Neither
a normal neurological examination nor a normal medical examination will rule
out the presence of dementia, however.
The final aspect of the examinations is the use of neurological and neuro-
radiological devices. These include measures of electrical activity in the brain
(EEG, evoked potential), measures of brain structure (CT scan, MRI), measures
of cerebral blood flow (rCBF, SPECT, PETT), and measures of intracranial pres-
sure (spinal tap). Each ofthese types of devices is useful in identifying specific
disorders but none are absolute: normal results again do not predict the absence
of dementia.
EEG measures have long been used in cases of dementia. In AD, many stud-
ies have shown slowing in EEG activity in more moderate to advanced cases
(e.g., Brenner, Ulrich, Spiker, Sclabassi, & Reynolds, 1986; Breslau, Starr,
Sicotte, Riga, & Buchsbaum, 1989; Israel, Kozarevic, & Sarorius, 1984; Saletu &
Anderer, 1988). Gunther et al., (1993) suggested that EEG could be effective in
detecting changes at rest as well as when the client was involved in active per-
ceptual or cognitive processing. Miyauchi and colleagues (1994) reported use-
ful but not individually diagnostic findings using Quantitative EEG (QEEG)
methods, as have Onofri and colleagues (1991) using event related potential in
AD and individuals with MS dementia.
EEG can be useful in documenting cerebral dysfunction and in identifying
subcortical lesions in diseases like MS. EEGs can also be utilized for the identi-
fication of certain types of seizures which may be seen secondarily in cases of
dementia. In some cases treatment of the seizures will markedly improve cog-
nitive as well as behavioral symptoms. The elimination of active seizures can
improve memory concentration, and general cognitive skills, and eliminate be-
havioral and psychological effects of partial complex seizures which can in-
clude depression, anxiety, panic, anger, aggression, and acting-out behavior.
More extended use has been made of devices that measure structural
changes in the brain. These have been used to identify general and specific
brain atrophy, identify focal points of damage, and identify space occupying le-
sions such as hematomas and tumors. Ventricular enlargement is also easily
seen by these tests. Differentiating normal and abnormal ventricular enlarge-
ment and atrophy, however, becomes increasingly difficult as the client grows
older. As noted earlier, there are benign and pathological causes of atrophy that
cannot be easily identified except through clinical correlation. In cases in
which atrophy is present, it is not always correct or advisable to assume imme-
diately that the atrophy is related to the dementia.
For example, Powell Mezrich, Coyne, Loesberg, and Keller (1993) found
that demented subjects were more likely to show third ventricle enlargement,
but that the sign was not diagnostic in individual cases. In other cases, sub-
stantial dementia may exist without any abnormal changes to the structure of
the brain. These tests are more useful when finding hematomas, tumors, or
other space occupying disorders. The tests are also useful in longitudinal eval-
uation of changes (DeCarli et aI., 1992).
Regional cerebral blood flow measures have opened another possible

method for analyzing brain function. Since these measures depend on brain
metabolism, they can remain normal despite apparent atrophy and show im-
pairment despite apparent intact structure. These measures can also differenti-
ate blood flow when the client is at rest and during active tasks, possibly
showing abnormalities in how the brain executes a task. With the introduction
of SPECT scans over the past decade, and the imminent introduction of an MRI
capable of measuring blood flow, these are becoming increasingly available and
cost-effective methods of evaluation.
As might be expected, blood flow is clearly reduced in AD (Bonte, Ross,
Chehabi, & Devous, 1986; Burns, Philpot, Costa, Ell, & Levy, 1989; Eberling, Ja-
gust, Reed, & Baker, 1992; Kumar et aJ., 1991) Sawada and colleagues (1992)
found cerebral blood flow useful in predicting the presence of dementia in Park-
inson's disease.
As with the other measures, cerebral blood flow appears a useful adjunct in
general to the study of the demented patient, but cannot differentiate reliably the
presence or type of dementia. However it may provide very useful clues in cer-
tain cases in which other measures are normal or equivocal. More research needs
to be done on this and the other measures, and clinical use is recommended as
long as clear clinical correlations and historical issues are considered as well.
Neuropsychological Testing
Neuropsychological testing has been widely used in the diagnosis of de-

mentia. However, such testing also has significant limitations. One of the ma-
jor limitations is a tendency for norms to become much more variable with
older normal populations. As a result, many tests of memory, motor speed and
problem solving show considerable overlap between the performance of per-
sons with mild dementia and normal individuals. Although there are unques-
tionably group differences on these measures between identified groups with
dementia and normal controls, the overlap between the groups makes individ-
ual diagnosis difficult and unreliable.
Another problem has been the issue of differentiating types of dementia.
Some clear-cut distinctions can be made, but they do not apply to all patients.
For example vascular dementias are much more likely to be accompanied by
lateralized sensory or motor symptoms or focal cognitive signs, but this is not
always the case. Frontal lobe signs are prominent in Pick's disease, but may be
seen in many other disorders as well.
The third problem is one of clinical correlation. Because of the overlap of pa-
tient and normal groups on many neuropsychological tests, the correlations with
ADLs and practical symptoms of dementia can range between slight and moder-
ate. The novelty of these tests can lead to overestimates of the functional disorder,
which in turn can lead to suggestions for institutionalization that is unnecessary.
A good neuropsychological examination should also include a thorough
personality evaluation which should consist of both objective and projective
tests if at all possible. Reliance should not be placed entirely on patient self-
report in this or any area of evaluation.
Dementia 133
With these caveats, neuropsychological tests are still quite useful in identify-
ing disorders that may be at the heart of the client's problem, an aid in differential
diagnosis both of type of dementia and the presence of dementia. Again, however,
they should not be used alone, but only in conjunction with other sources of data.
The Diagnostic Process
The diagnostic process is, thus, a multilevel process aimed at determining

the presence of dementia and its etiology. To determine that dementia is pres-
ent, there is only a need to demonstrate the presence of (1) memory problems,
and (2) other cognitive problems which, in turn, lead to impairment in occupa-
tional and/or social functioning. The remainder of the differential lies in estab-
lishing the etiology of the disorder according to the criteria discussed in each
area. This latter task requires the full range of diagnostic approaches, with dif-
ferent strategies having a more significant role in different types of cases. In
general, a complete evaluation will lead to a satisfactory explanation for the dis-
order, although final confirmation may not be available after the death of the
client given the current state of our diagnostic skills.
Differential Diagnosis
There are several major disorders for differential diagnosis. The most obvi-
ous are the deliriums. The symptoms in delirium are generally less stable and
much more variable over time. Delirium and dementia may coexist, making di-
agnosis difficult. History may also be useful in making the discrimination and
establishing a clear etiology.
Amnestic disorders are differentiated from dementias by the absence of an
associated cognitive disorder. However, some systems would consider these de-
mentias, along with cases of cognitive disorder without memory disorder,
which is classified under DSM-N as Cognitive Disorder NOS. Mental retarda-
tion is defined by its onset in childhood, and both disorders may be diagnosed
if the individual has symptoms of both.
Schizophrenia shows overlapping symptoms, but generally has an earlier
age of onset. In the elderly without a history of schizophrenia, the dementias
or delirium must be considered the more likely diagnosis. However, an indi-
vidual with life-long schizophrenia can develop dementia in later life; this
would be marked by lower functioning, memory, and cognitive skills than they
demonstrated throughout their lives.
Perhaps the diagnosis most often confused with dementia is depression. In
cases where the client is not depressed, this is not a problem. In cases without a
history of major depression and without a clear etiology for the depression (such
as a loss of a mate), delirium or dementia again become more likely. A thorough
history is absolutely necessary to see whether the course of cognitive decline
is consistent with a specific form of dementia. If so, appropriate medical and
neuropsychological tests can be used to confirm or disconfirm the diagnosis. If
the history suggests depression, then medical and neuropsychological tests can
also confirm this or suggest the concurrent existence of dementia. A thorough

examination at all levels discussed here will generally lead to a reasonable dis-
crimination (Golden et a1., 1992; Lamberty & Bieliaukas, 1993).
A final category which should be considered is malingering. Such a dis-
order generally requires some secondary motivation, which is rare in cases of
dementia. In general, however, a thorough examination will reveal glaring in-
consistencies in findings across and within methods. However, such evalua-
tions must be made with the awareness that there is only a moderate correlation
between different methods of evaluation.
TREATMENT
There is no definitive general treatment for the dementias. Some of these

disorders are irreversible, while others may respond to timely and appropriate
treatment with partial or full remission. Most can respond to behavioral and
chemical interventions, as well as manipulation of the environment. We will
discuss each of these alternatives.
Treatable Disorders
Many of the disorders that cause dementia have medical treatments that
can fully or partially alleviate the disorder and the resultant cognitive symp-
toms. These disorders include diabetes, liver and kidney failure, tumors, can-
cers, endocrine disorders, nutritional disorders, heart disorders, lung disorders,
blood disorders, hematomas, normal pressure hydrocephalus, and other related
problems. The specific treatments for these disorders are not within the scope
of this chapter, but their identification and treatment is a key in any initial med-
ical "workup" of the demented client.
Pharmaceutical Intervention
Pharmaceutical intervention falls into several classes. The first of these in-
volve medication specific to one disorder that generally addresses motor symp-
toms in such disorders as Parkinson's disease or MS. Since these medications
do not address the symptoms of dementia per se, they are not covered in this
chapter. The second class of medications attempts to limit or reverse the direct
cognitive effects of dementing disorders. The final class of medication ad-
dresses the behavioral effects of dementia. We examine the effects of the latter
two classes of medications.
Antidementia Medications
Medications attempt to reverse the cognitive effects of AD and other de-
mentias are relatively new, although the investigation of substances that might
reverse dementia has been popular since it was discovered that some forms of
Dementia 135
dementia were due to diseases like syphilis and others were due to vitamin and
nutritional deficiencies. Medications like folate and vitamin B12 have been pop-
ular although results have been disappointing (e.g., Chanarin, Deacon, Lumb,
and Perry, 1989; Goodwin, Goodwin, & Garry, 1983; Levitt & Karlinsky, 1992;
Shorvon, Carney, Chanarin, & Reynolds, 1980; Shulman, 1967; Sneath, Cha-
narin, Hodkinson, McPherson, & Reynolds, 1973). Some dementias are clearly
caused by deficiencies in such substances, but they comprise a very small part
of the dementia population overall.
More promising medications attempt to increase levels of acetylcholine in
the brain, based on the theory that AD and perhaps other disorders are related
to a deficiency in this neurotransmitter. Others use different pathways but with
similar goals. Although none of these drugs have been studied sufficiently to be
considered "proven," they are all of interest at the time this chapter was writ-
ten. Nearly all of this research has been conducted within the past 20 years,
with beliefs about the efficacy of the drugs ranging from negative to more opti-
mistic. The hope is that within the next decade a set of medications will be
identified that can improve or retard degeneration in cognitive and memory
performance in some cases of dementia.
These medications include such substances as oxiracetam, nicergoline, mi-
lacemide, nebracetam fumurate, denbufylline, pyritinol, and piracetam. Stud-
ies have shown cognitive improvement in animals (Artola & Singer, 1987; Banfi
& Dorigotti, 1986; Giurgea, 1972; Johnson & Asher, 1987; Kuhn et al., 1988;
Mondadori & Classen, 1984; Ohno, Yamamoto, Kitajima, & Ueki, 1990; Spignoli
et a1., 1986) and humans (e.g., Bottini et al., 1992; Cutler et a1., 1993; Fischhof
et a1., 1992; Herrmann & Stephan, 1992; Saletu et a1., 1992; Urakami et a1., 1993;
Zappoli et al., 1991). Improvements have been shown in a wide variety of
memory areas, cognitive function, brain metabolism, brain electrical activity,
and behavior.
The patients who took medication generally did better than patients who
received placebo. Not all patients who responded to the medications showed
improvement. Some of the patients on the medication, however, did show
dramatic improvements. In well-constructed double-blind studies, the edge,
or the treated group as a whole, was clearly significant. The development of
these substances is still in its infancy. We will likely see better drugs devel-
oped in the future. We are also likely to find that certain symptom constella-
tions and certain etiological actors play a major role in determining who
responds and who does not respond to these medications. The research in
this area is quite exciting, and it is likely that these "antidementia" medica-
tions will be a major part of the treatment of persons with dementia over the
next decade and beyond.
Behavioral Control
The other use of medication is aimed at the behavioral and psychiatric
symptoms which may accompany dementia. These include aggressiveness, ag-
itation, screaming, hostility, hallucinations, dementia, eating disorders, sleep
disturbance, inappropriate sexual behavior, and excessive wandering behavior.
These behaviors are extremely disruptive to caregivers and may make adequate
care impossible in some cases. These behaviors can be treated behaviorally or

using a pharmaceutical approach.
Despite over three decades of using psychoactive medications for treating
the elderly demented, well-run studies or clear results have largely been lack-
ing and physicians have been more dependent on "feel" than fact. A metanaly-
sis of prior studies by Schneider, Pollock, and Lyness (1990) found that the
medications were better than placebo, but only by a small amount, regardless of
the medication employed. In general, when there is improvement, we see de-
creases in agitation, but no improvement in cognition. In some cases, the pa-
tient may become overly fatigued and show reduced behaviors in all areas.
Rapp, Flint, Herrmann, and Proulx (1992), in an excellent review, suggest
that aggression, restlessness, delusions, hallucinations, and some inappropriate
sexual behavior respond to medication, but that wandering or inappropriate noise
does not. Since no drug seems to be more useful than any other (see Carlyle, An-
cill, & Sheldon, 1993), the authors suggest the use ofperphenazine or loxapine to
minimize side effects. Drugs must be tried at their highest dose (equivalent to
about 300 mg of chlorpromazine) for at least a month to test the effectiveness of a
medication. Drug holidays are recommended as well. The authors found the an-
tipsychotic medication to be greatly preferable to the benzodiazepines.
Clozapine is an atypical antipsychotic medication that has been suggested for
those who cannot tolerate other antipsychotic medications. Oberholzer, Hendrik-
sen, Monsch, Heierli, and Stahelin (1992) suggested its use as an alternative in the
demented population, but data and controlled results again remain limited.
An alternative class of drugs that has been investigated restore serotogenic
functions in the brain (Altman & Normile, 1988; Gottfries, Adolfsson, & Aquilo-
nius, 1983; Strathmann, 1988). Early studies with traumatic dementias sug-
gested that this class of drugs might be useful (Pinner & Rich, 1988; Simpson &
Foster, 1986). Olafsson and colleagues (1992), however, failed to find significant
improvement in patients with primary degenerative dementia.
Schneider and Sobin (1992) indicated that other classes of drugs have been
used as well, including lithium and beta blockers. In general, findings with
lithium have been disappointing; however, there have been no well-controlled
studies at reasonable dosage levels. Similarly poor results have been found for
beta-blockers even though they are often prescribed in nursing home and reha-
bilitation settings.
Rosen, Mulsant, and Wright (1992) emphasize the need for the physician (be-
fore using medications) to identify the roots of agitation and related behavior.
These may include pain and discomfort, illness, delirium, depression, psychosis,
distress, or caregiver burden or burnout. In the last case, treatment needs to be di-
rected toward the caregiver rather than the patient. In the other cases, treatment
should be geared toward the actual cause rather than providing general treatment
with psychoactive medication.
Overall, the use of these medications has produced mediocre results that
are only slightly better than use of placebos. Much of the use in clinical settings
is ineffective in terms of monitoring and ability to improve patients' behavior
without significant side effects. These drugs work in some patients, but place-
bos appear to work just as well in a significant minority of clients. Much more
research is needed to identify when these medications can help and under what
Dementia 137
conditions. More careful methods of assessing the etiology of symptoms is also

strongly recommended.
Behavioral and Environmental Intervention
Behavioral and environmental intervention attempt to evaluate what as-

pects of the environment precipitate behaviors in the client. Once these are
identified, changes can be made in the environment so that cues that elicit the
unwanted behavior are avoided or behavior modification techniques are em-
ployed to alter the response of the client to the environment. While behavior
modification techniques can be used with dementia clients, more progress is
made when environmental cues can be altered, as the rate of new learning in
dementia is usually slow and uneven. Behavioral interventions may also be dif-
ficult when there is a lack of attention to "new cues" that might be used to sig-
nal appropriate behaviors. Such cues, although obvious to others, may not be
noticed by an individual with perseverative tendencies or perceptual defects as
is often seen in dementia.
Several aspects of the environment are easily identified as problems with
dementia clients. One major area is changes in the environment. Individuals
with dementia, by definition, have difficulties with memory and new learning.
Such individuals must rely on old learning and habits to maintain appropriate
behavior. When the environment changes, these behaviors may become inap-
propriate. For example, a dementia client may have lived in a given house for
many years and knows the way to the bathroom from the bedroom. In an at-
tempt to help the client, the house is altered or the client is moved to another
residence to be nearer relatives or to an institution. The client's appropriate
"spatial" behavior suddenly would become "inappropriate" because the path to
the bathroom may now be the path to someone else's bedroom. The stroll to the
store and back suddenly becomes roaming, as the individual is unable to reach
the store or get back to home.
Thus, the basic rule is to change as little as possible. When confronted with
tasks that depend only on overlearned skills, the mild to moderate dementia
client can do well. However, this very reliance on overlearning impedes effec-
tiveness in a new environment. Clients do better when left in their own envi-
ronment than when given a new environment. (A new environment for client
with motor deficits, but who is cognitively intact, is a very different situation
which is often positive.) Clients moved into new environments may suddenly
become identified as having dementia because of their inability to cope. This
may be mistaken as a sudden onset dementia because of the environmental
change, when in fact the disorder may have been slowly progressive.
This general rule applies to the full range of life activities. The early de-
mentia client may be dissuaded from going to work or carrying on normal recre-
ational activities, which simply adds to the client's dysfunction. In all of these
cases, the client may need help: reduced hours at work, an aide at home to help
in more complex areas, family support, help with recreational activities, and
the like. Interventions that minimize the amount of change the person must en-
dure are usually more effective.
The difficulty for caregivers is concern for safety of the client when re-
maining in the old environment versus increased safety and access to family or
caregivers in a new environment. However, from both a cost perspective and a
family health perspective, the hiring of aides or occasional family visits may
work much more effectively. There are areas in which this becomes difficult,
however: in clients with sufficient motor deficits to need 24-hour care and
in driving. The combination of significant motor and cognitive deficit is an
especially difficult one as the prior environment may be unsafe or unwieldy.
However, because such clients are less likely to roam, some of these concerns
become less of an issue. As much as possible, however, the client will do better
in a familiar environment. The second major area of concern is driving. Because
of overlearned skills, clients may drive without difficulty in areas they are fa-
miliar with, but easily get lost in other areas. Motor skills may appear adequate
except in unusual driving situations. However, deficits will appear in emer-
gency situations. Clients may even be able to pass routine driving tests, making
driving decisions very difficult as well as debatable.
When changes are made, they need to be as small as possible. It is not sur-
prising that moving a dementia client from a situation where he or she lives alone
into a home with children and grandchildren may lead to irritability and aggres-
sive behavior (on everybody's part). Moving into an institution where freedom is
restricted can lead to aggression and roaming as can staff who treat clients as ob-
jects rather than people. It is important to recognize that individuals with de-
mentia see and remember themselves as fully functional adults who are insulted
and irritated when treated inappropriately. Combine this with emotional lability
and judgment defects, and there is a high likelihood for inappropriate behavior.
However, the change must be in the environment rather than the client.
When environments must change, the new environment should be as sim-
ple, concrete, and clear as possible so that the client gets adequate social and
environmental support that emphasizes maximum independence and freedom.
The more we ask the client to become institutionalized, the more we are likely
to see outbreaks of inappropriate behaviors. Lines that allow the client to get
from one place to another, access to simple kitchen activities, access to a wide
range ofrecreational activities, access to reading material, papers, radio, televi-
sion, music, and other normal aspects of life minimize negative reactions.
When negative reactions occur, a behavioral analysis is necessary to ana-
lyze the conditions and environmental cues involved. When environmental
change is not possible, then the client's behavior must be changed. It is strongly
recommended that the client be told of the problem and allowed to be involved
as much as possible in a contract for the solution. This may involve allowing
more access to tape players at certain types of the day, negative consequences
for inappropriate sexual behavior, or any other intervention consistent with be-
havioral analysis. Active, simple, and very consistent behavioral programs have
the highest likelihood of success. Any agreements or contracts must be written
or recorded in a form that the client can review, because of the likely impact of
memory problems on any agreement.
These suggestions sound basic, but they work well in a wide variety of con-
ditions. However, one additional area is the question of the caregiver. Whether
we deal with an aide, family members, or institutional staff there are many hu-
man interactions that can cause significant problems. Attention from one or
Dementia 139
more people in the environment may be dependent on acting out. Stimulation

may also be received when acting out. The stress on a family unit that has a de-
menting relative move in may create severe psychological problems that are
communicated to the patient. In many cases, patient behavior is manageable,
but the effort is too much for the caregivers. Thus, close attention to the mental
health of the caregiver (whether family or institutional or personal) is a clear
and important aspect of any program.
This should include relief from the client, which might involve day pro-
grams or activities with friends or relatives. In an institution, staff rotation may
be a useful technique. If the client is at home, no family member should be ex-
pected to give up his or her life to take care of a patient.
Sleep
Another important related area is the question of sleep. "Sundowning," or

the loss of cognitive and emotional control as the day goes on, has been used
as an explanation for many problems in the dementia client. Although sun-
downing is usually associated with sleep disturbance, Bliwise, Carroll, Lee,
Nekich, and Dement (1993) have suggested that the behaviors included under
"sundowning" exist throughout the day, but may have more impact on nursing
staff as the day goes on. Sleep disturbance may produce sun downing in indi-
viduals who follow different circadian rhythms, so they are alert when we are
asleep and vice versa. This alone will produce clients sleepy at different times,
hungry at different times, irritable at different times, and ready for activities
at different times, a combination that could lead to excessive problems in in-
stitutions that maintain schedules for the institution and its staff rather than
for the individual client.
There are many reasons for sleep disturbance in the elderly in general and
in the dementia patient (see Bliwise, 1993). These causes include problems in
circadian rhythms and difficulty in adjusting biologically to new schedules.
They also include sleep-related respiratory disturbance, REM sleep deprivation,
naps and resting during the day, excessive time in bed during the day, lack of
daily activity, depression, seizures, sleep apnea, neuroleptic induced akathisia,
and deterioration of the suprachiasmatic nucleus. The presence of any number
of these factors can seriously interfere with adequate sleep, leading to behav-
ioral problems throughout the day. While some of these symptoms may appear
to be helped by medication, medication may not allow for adequate REM sleep
or actually change ill-fitting circadian patterns. Failure to adequately address
these problems will result in continuing behavioral dysfunction, and indeed
may increase the apparent level of dementia.
Practice
One of the great strengths of the brain is its ability to repair itself through
reorganization of axonal connections and the development of new axonal con-
nections among healthy neurons (Golden et al., 1992). Swaab (1991) points out
that in other organs of the body, the principle of "wear and tear" applies: the
more you use it, the shorter time it will function properly. The brain, however,
works on a "use it or lose it" principle. Skills we do not use simply disappear
while those that we practice and reinforce remain with us longer.
This appears to arise out of the fact that abilities that are practiced will de-
velop new underlying patterns of axonal representation that will allow them to
continue. If a task is not practiced, there is no reason for the brain to maintain
systems for that behavior. Hence, it is quickly lost as brain injury or deteriora-
tion occurs. As a consequence, individuals with dementia of any kind will do
better the more active they are in the widest range of activities. As we give ac-
tivities up, they are lost quickly in the degenerating brain, whereas those we
practice can be better maintained or partially regained.
While practice does not maintain the brain itself or keep neurons from dy-
ing, practice maintains skills on a behavioral level and makes the best use of
those areas of the brain that keep their function. The effects of practice cannot
overcome the basics of neuronal loss that will limit the amount of behavior that
can be retained, but it will allow for maximal performance. We see demented
clients who have little left but can still play poker or sing or perform some other
highly specific and overpracticed task.
Thus, the best programs at home or in institutions emphasize the patient's
independence: doing as much as possible for themselves despite slowness or
inaccuracy. This includes all basic skills: dressing and hygiene, food prepara-
tion, household care, recreation and the full range of ADLs discussed earlier.
In some cases, the individual will need support and review. However, it is es-
sential that caregivers not "take the easy way out" by doing something because
it is easier than waiting for the client, or because the client becomes depressed
and refuses.
An important aspect of any program that emphasizes supervision is safety.
For example, in some clients, cooking needs to be restricted to microwaves and
toasters because of dangers in using a stove (which can be easily inactivated by
turning off gas supplies or removing fuses). Fireplace use and driving may re-
quire restrictions. Other problems may occur because of motor limitations, but
there are literally thousands of "aids" that can help the patient with motor prob-
lems be more independent (although the presence of both motor and cognitive
problems may limit their use). Independence involves some risk and creativity,
but is well worth maximizing so as to maximize the quality of life of the client.
SUMMARY
As our society ages, dementia has become an increasingly common and se-
rious problem both to the individual and to society as a whole. Dementias come
in many different forms with many disparate etiologies. The diagnosis of de-
mentia is dependent on identifying the central symptoms of a dementia (mem-
ory loss and cognitive loss) and on the more complex task of identifying the
underlying etiology using history, a survey of ADL skills, medical and radio-
logical examinations, screening tests, and neuropsychological examinations.
Many forms of dementia are untreatable, but current research is attempting to
identify medications that can improve motor, cognitive, and behavioral symp-
Dementia 141
toms. Other treatment has focused on the need of the client for a familiar and
stable environment, and using environmental manipulations along with behav-
ior modification to control inappropriate behavior. The need for continued
practice and independence is also emphasized.
REFERENCES
AlafuzoffI. (1992). The pathology of dementias: An overview. Acta Neurologica Scandinavica, 139,
8-15.
Alafuzoff, 1., Ronnberg, A., & Asikainen-Gustafsson, S. (1991). Clinical to histopathological corre-
lation ofthe diagnosis of dementia. International Psychogeriatrics, 3, 69-74.
Altman, H., & Normile, H. (1988). What is the nature ofthe role of the serotonergic nervous system
in learning and memory: Prospects for the development of a treatment strategy for senile de-
mentia. Neurobiology of Aging, 9, 627-639.
Alzheimer, A. (1898). Neuere Arbeiten uber die Dementia senilis und die auf atherimatoser
Gefasserk rankung basierended Gehirnkrankheiten. Monatsschrift fuer Psychiatrie und Neu-
rologie, 3, 101-115.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders
Anthony, J., LeResche, L.. Niaz, U., von Korff, M., & Folstein, M. (1982). Limits of the mini-mental
state as a screening test for dementia and delirium among hospital patients. Psychological
Medicine, 12, 397-408.
Artola, A., & Singer, W. (1987). Long term potentiation and NMDS receptors in rat visual cortex. Na-
ture, 330, 649-652.
Ashford, J. W., Kumar, V., Barringer, M.. Becker, M., Bice, J., Ryan, N., & Vicari, S. (1992). Assessing
Alzheimer severity with a global clinical scale. International Psychogeriatrics, 1, 55-74.
Ball, M. (1980). Features of Creutzfeldt-Jakob disease in brains of patients with familial dementia
of the Alzheimer's type. Canadian Journal of Neurological Sciences, 7,51-57.
Banfi, S., & Dorigotti, 1. (1986). Experimental behavioral studies with oxiracetam on different types
of chronic cerebral impairment. Clinical Neuropharmacology. 9, 519-526.
Beck, E., & Daniel, P. (1987). Neuropathology of transmissible spongiform encephalopathies. In S.
Pruisner & M. McKinley (Eds.), Prions: Novel infectious pathogens causing scrapie and
Creutzfeldt-Jakob disease. San Diego: Academic.
Berg, R., Franzen, M., & Wedding, D. (1994). Screening for brain impairment. New York: Springer.
Berman, M. (1990). Severe brain dysfunction: Alcoholic Korsakoff's syndrome. Alcohol Health and
Research, 14,120-129.
Biggins, C. A., Boyd, J., Harrop, F., Madeley, P., Mindham, R., Randall, J., & Spokes, E. (1992). A con-
trolled longitudinal study of dementia in Parkinson's disease. Journal of Neurology, Neuro-
surgery, and Psychiatry. 55, 566-571.
Bliwise, D., Carroll, J., Lee, K., Nekich, J., & Dement, W. (1993). Sleep and "sundowning" in nursing
home patients with dementia. Psychiatry Research, 48, 277-292.
Bliwise, D. L. (1993). Sleep in normal aging and dementia. Sleep, 16,40-81.
Bonte, F. J., Ross, E. D., Chehabi, H. H., & Devous, M. D. (1986). SPECT study of regional cerebral
blood flow in Alzheimer's disease. Journal of Computed Assisted Tomography, 10,579-583.
Bottini, G., Vallar, G., Cappa, S., Monza, G. C., Scarpini. E., Baron, P., Cheldi, A., & Scarlato, G.
(1992). Oxiracetam in dementia: A double blind, placebo-controlled study. Acta Neurologica
Scandinavica, 86, 237-241.
Brandt, J., & Butters, N. (1986). The alcoholic Wernicke-Korsakoff syndrome and its relationship
to long term alcohol abuse. In G. Grant & K. Adams (Eds), Neuropsychological assessment of
neuropsychiatric disorders. New York: Oxford University Press.
Brenner, R., Ulrich, R., Spiker, D., Sclabassi, R., & Reynolds, C. (1986). Computerized EEG spectral
analysis in elderly normal, demented, and depressed subjects. Electroencephalography and
Clinical Neurophysiology. 64, 483-492.
Breslau, J., Starr, A., Sicotte, N., Higa! J., & Buchsbaum, M. (1989). Topographic EEG changes with
normal aging and SDAT. Electroencephalography and Clinical Neurophysiology. 40, 281-289.
Brown, P. (1989). Central nervous system amyloidoses: A comparison of Alzheimer's disease and
Creutzfeldt-Jakob disease. Neurology, 39, 1103-1105.
Bums, A., Philpot, M. P., Costa, D. C., Ell, P. J., & Levy, R. (1989). The investigation of Alzheimer's
disease with single photon emission tomography. Journal of Neurology, Neurosurgery and
Psychiatry, 52, 248-253.
Carlyle, W., Ancill, R., & Sheldon, L. (1993). Aggression in the demented patient: A double blind
study ofloxapine versus haloperidol. International Clinical Psychopharmacology. B, 103-108.
Chanarin, I., Deacon, R., Lumb, M., & Perry, J. (1989). Cobalaminfolate interrelationships. Blood Re-
view, 3, 211-215.
Copeland, J., Kelleher, N., Kellett, J., Gourlay, A., & Gurland, B. (1976). A semistructured clinical in-
terview for the assessment of diagnosis and mental state in the elderly. Psychological Medi-
cine, 6, 439-449.
Copeland, J. R., Dewey, N., Henderson, A., Kay. D.• & Neal, C. (1988). The Geriatric Mental State
(GMS) used in the community: Replication studies of the computerized diagnoses AGECAT.
Psychological Medicine, lB, 219-223.
Corey-Bloom. J., Galasko. D.• Hofstetter, R., Jackson, J.• & ThaI. L. (1993). Clinical features distin-
guishing large cohorts with possible AD, probable AD, and mixed dementia. Journal of the
American Geriatrics Society, 41, 31-37.
Cummings, J., & Benson, D. (1992). Dementia. Toronto: Butterwirth-Heinemann.
Cutler, N. R., Fakouhi. D., Smith. W. T., Hendrie, H. C., Matsuo, F., Sramek, J. J .• & Herting, R. L.
(1993). Evaluation of multiple doses ofmilacemide in the treatment of senile dementia of the
Alzheimer's type. Journal of Geriatric Psychiatry and Neurology. 6, 115-119.
DeCarli, C., Haxby, J., Gillette, J., Teichberg, D., Rapoport. S., & Schapiro, M. (1992). Longitudinal
changes in lateral ventricular volume in patients with dementia of the Alzheimer type. Neu-
rology. 42, 2029-2036.
Eberling, J. L., Jagust. W. J., Reed, B. R., & Baker. M. G. (1992). Reduced temporal lobe blood flow in
Alzheimer's disease. Neurobiology of Aging, 13,483-491.
Edwards, A. J. (1993). Dementia. New York: Plenum Press.
Evenhuis, H. M. (1992). Evaluation of a screening instrument for dementia in aging mentally re-
tarded persons. Journal of Intellectual Disability Research, 36, 337-347.
Fields, S., Fulop, G., Sachs, C., Strain, J., & FilIit. H. (1992). Usefulness of the neurobehavioral cog-
nitive status examination in the hospitalized elderly. International Psychogeriatrics, 4, 93-102.
Fischhof, P., Saletu, B.• Ruther, E.• Litschauer, G.• Moslinger-Gehmayr. R., & Herrmann, W. (1992).
Therapeutic efficacy of pyritinol in patients with senile dementia of the Alzheimer type
(SDAT) and multi-infarct dementia (MID). Neuropsychobiology. 26, 65-70.
Folstein. M., Folstein. S., & McHugh, P. (1975). "Mini-mental state": A practical method for grading
the cognitive states of patients for the clinician. Journal of Psychiatric Research, 12, 189-198.
Fratiglioni, L .• Grut, M., Forsell, Y., Viitanen, M., & Winblad, B. (1992). Clinical diagnosis of
Alzheimer's disease and other dementias in a population survey. Archives of Neurology, 49,
927-932.
Galasko, D., Klauber. M., Hofstetter, R., Salmon, D., Lasker, B., & ThaI. L. (1990). The MMSE in the
early diagnosis of Alzheimer's disease. Archives of Neurology, 47, 49-52.
Giurgea. C. (1972). Vers une pharmacologie de l'activite integrative du cerveau: Tentative du con-
cept nootrope en psychopharmacologie. Actual Pharmacology, 25,115-156.
Golden, C.• Osmon. D., Moses, J.• & Berg. R. (1981). Interpretation of the Halstead-Reitan Neu-
ropsychological Battery. New York: Harcourt Brace Jovanovich.
Golden, C., Zillmer, E., & Spiers. M. (1992). Neuropsychological assessment and intervention.
Springfield, IL: Thomas.
Goodwin, J. S .• Goodwin. J. M., & Garry, P. J. (1983). Association between nutritional status and cog-
nitive functioning in a healthy elderly population. Journal of the American Medical Associa-
tion, 249. 2917-2921.
Gottfries, C. (1991). Classifying organic mental disorders and dementia-A review of historical per-
spectives. International Psychogeriatrics, 3, 9-17.
Gottfries, C., Adolfsson, R., & Aquilonius, S. (1983). Biochemical changes in dementia disorders of
the Alzheimer type (AD/SDAT). Neurobiology of Aging, 4, 261-271.
Gunther, W., Giunta. R., Klages, U .• Haag. C., Steinberg, R., Satzger, W., Jonitz. L., & Engel, R. (1993).
Findings of electroencephalographic brain mapping in mild to moderate dementia of the
Dementia 143
Alzheimer type during resting, motor, and music-perception conditions. Psychiatry Research:
Neuroimaging, 50, 163-176.
Gurland, B., Kuriansky, J., Sharpe, L., Simon, R, & Stiller, P. (1977). The comprehensive assessment
and referral evaluation (CARE). International Journal of Aging and Human Development, 8,
9-42.
Gustafson, L. (1992). Clinical classification of dementia conditions. Acta Neurologica Scandinav-
ica, 139,16-20.
Herrmann, W., & Stephan, K. (1992). Moving from the question of efficacy to the question ofthera-
peutic relevance: An exploratory reanalysis of a controlled clinical study of 130 inpatients
with dementia syndrome taking piracetam. International Psychogeriatrics, 4, 25-44.
Holttum, J., & Gershon, S. (1992). The cholinergic model of dementia, Alzheimer type: Progression
from the unitary transmitter concept. Dementia, 3, 174-185.
Israel, J., Kozarevic, N., & Sarorius, N. (1984). Source book of geriatric assessment. Basel, Switzer-
land: Karger.
Jacobson, R, Acker, c., & Lishman, W. (1990). Patterns of neuropsychological deficit in alcoholic
Korsakoff's syndrome. Psychological Medicines, 20, 321-334.
Jarvik, L. F. (1992). Possible biological basis for a major memory disorder. In J. Morley, R Coe, R
Strong, & G. Grossbergs (Eds.), Memory function and age related disorders. New York:
Springer.
Johnson, J. W., & Asher, P. (1987). Gylcine potentiates the NMDS response in cultured mouse brain
neurons. Nature, 325, 31-35.
Jones, H., Hedley-White, T., & Friedberg, S. (1985). Ataxic Creutzfeldt-Jakob disease: Diagnostic
techniques and neuropathological observations in early disease. Neurology, 35, 254-357.
Jung, R, & Solomon, K (1993). Clinical practice and psychiatric manifestations of Pick's disease. In-
ternational Psychogeriatrics, 5, 187-202.
Kay, D., Henderson, A., Scott, R, Wilson, J., Rickwood, D., & Grayson, D. (1985). Depression and de-
mentia among the elderly living in the Hobart community. Psychological Medicine, 15,
771-788.
Kraepelin, E. (1896). Psychiatrie: Ein Lehrbuch fUr Studierende und Aerzte. Leipzig, Germany: Ver-
lag von Johann Ambrosius Bath.
Kuhn, F. J., Schingnitz, G., Lehr, E., Montagna, E., Hansen, H. D., & Giachetti, A. (1988). Pharma-
cology ofWEB-1881-F, a central cholinergic agent, which enhances cognition and cerebral me-
tabolism. Archives of Internal Pharmacodynamic Therapy, 292, 13-34.
Kumar, A., Schapiro, M. B., Grady, C., Haxby, J. V., Wagner, E., Salerno, J. A., Friedland, R P., &
Rapoport, S. (1991). High-resolution PET studies in Alzheimer's disease. Neuropsychophar-
macology, 4, 35-46.
Kurz, A., Haupt, M., Pollmann, S., & Romero, B. (1992). Alzheimer's disease: Is there evidence of
phenomenological subtypes'? Observations from a longitudinal study. Dementia, 3, 320-327.
Lamberty, G. J., & Bieliauskas, L. A. (1993). Distinguishing between depression and dementia in the el-
derly: A review of neuropsychological findings. Archives of Clinical Neuropsychology, 8, 149-170.
Levitt, A. J., & Karlinsky, H. (1992). Folate, vitamin B,2 , and cognitive impairment in patients with
Alzheimer's disease. Acta Psychiatrica Scandinavica, 86, 301-305.
Marsden, C., & Fahn, S. (1987). Movement disorders II. London: Butterworths.
Mendez, M., Selwood, A .. Mastri, A., & Frey, W. (1993). Pick's disease versus Alzheimer's disease:
A comparison of clinical characteristics. Neurology, 43, 289-292.
Mielke, R, Herholz, K, Grond, M., Kessler, J., & Heiss, W. (1992). Severity of vascular dementia is
related to volume of metabolically impaired tissue. Archives of Neurology, 49, 909-913.
Miller, B., Cummings. J., Villanueva-Meyer, J., Boone, K, Mehringer, C., Lesser, I., & Mena, I. (1991).
Frontal lobe degeneration: Clinical, neuropsychological, and SPECT characteristics. Neurol-
ogy, 41,1374-1382.
Miyauchi, T., Hagimoto, H., Ishii, M., Endo, S., Tanaka, K, Kajiwara, S., Endo, M., Kajiwara, A., &
Kosaka, K. (1994). Quantitative EEG in patients with presenile dementia of the Alzheimer
type. Acta Neurologica Scandinavica, 89, 56-64.
Mondadori, C., & Classen, W. (1984). Effect of oxiracetam on the performance of aged rates in a one
way active avoidance situation. Clinical Neuropharmacology, 1984, 770-771.
Nissen, T., Mellgren, S., & Selseth, B. (1989). Demens evaluert med MMSE. Tidsskriftforden Norske
Laegeforening, 109,1158-1162.
Oberholzer. A.. Hendriksen. C.• Monsch. A.• Hieierli. B.• & Stahelin. H. (1992). Safety and effective-
ness of low-dose clozapine in psychogeriatric patients: A preliminary study. International
Psychogeriatrics, 4. 187-195.
Ohno. M.• Yamamoto. T.• Kitajima. I.. & Ueki. S. (1990). WEB 1881 F ameliorates impairment of
working memory induced by scopolamine and cerebral ischemia in the three panel runway
task. Japanese Journal of Pharmacology. 54, 53-60.
Olafsson. K.. Jorgensen. S .• Jensen. H.• Bille. A.• Arup. P.• & Andersen. J. (1992). Fluvoxamine in the
treatment of demented patients: A double blind. placebo controlled study. Acta Psychiatrica
Scandinavica. 85. 453--456.
Onofri. M.• Gambi. D.• Del Re. M.• Fulgente. T.• Bazzano. S .• Colamartino. P.• & Malatesta. G. (1991).
Mapping of event related potentials to auditory and visual odd ball paradigms in patients af-
fected by different forms of dementia. European Neurology. 31. 259-269.
Overall. J. E.• & Schaltenbrand. R. (1992). The SKT neuropsychological test battery. Journal of Geri-
atric Psychiatry and Neurology. 5. 220-227.
Parsons. 0 .• & Nixon. S. (1993). Neurobehavioralsequelae of alcoholism. Neurologic Clinics. 11.
205-218.
Pinner. E.• & Rich. C. (1988). Effects oftrazodone on aggressive behavior in seven patients with or-
ganic mental disorder. American Journal of Psychiatry. 145, 1295-1296.
Powell. A. L.• Mezrich. R. S .• Coyne. A. C.• Loesberg. A.• & Keller. I. (1993). Convex third ventricle: A
possible sign for dementia using MRI. Journal of Geriatric Psychiatry and Neurology. 217-221.
Rapp. M. S .• Flint. A.• Herrmann. N.• & Proulx. G. (1992). Behavioral disturbances in the demented
elderly: Phenomenology. pharmacotherapy. and behavioural management. Canadian Journal
of Psychiatry. 37. 651-657.
Roman. G.• Tatemichi. T.• Erkinguntti. T.• Cummings. J.. Masdeu. J.. Garcia. J.• Amaducci. L.• Orgogozo.
J.• Brun. A.• Hofman. A.• Moody. D.• O·Brien. M.• Yamaguchi. T.• Grafman. J.. Drayer. B.• Bennet.
D.• Fisher. M.• Ogata. J.• Kokmen. E.• Bermejo. F.• Wolf. P.• Gorelick. P.• Bick. K.. Pageau. A.• Bell.
M.• DeCarli. C.• Culebras. A.• Korczyn. Z .• Bogousslavsky. J.• Hartmann. A.• & Scheinberg. P.
(1993). Vascular dementia: Diagnostic criteria for research studies. Neurology. 43. 250-260.
Rosen. J.• Mulsant. B.• & Wright. B. (1992). Agitation in severely demented patients. Annals of Clin-
ical Psychiatry. 4. 207-215.
Roth. M.• Tym. E.• Mountjoy. C.• Huppert F.• & Hendrie H. (1986). CAMDE: A standardized instru-
ment for the diagnosis of mental disorder in the elderly with special reference to the early de-
tection of dementia. British Journal of Psychiatry. 149. 698-709.
Sabe. L.• Jason. L.• Juejati. M.• Leiguarda. R.• & Starkstein. S. (1993). Sensitivity and specificity of the
mini-mental state exam in the diagnosis of dementia. Behavioural Neurology. 6. 207-210.
Saletu. B.• & Anderer. P. (1988). EEG Mapping in der psychiatrischen diagnose und thera-
pieforschung. In B. Saletu (Ed.). Biologische Psychiatrie. New York: Springer-Verlag.
Saletu. B.• Anderer. P.• Fischhof. P.• Lorenz. H.• Barousch. R.. & Bohmer. F. (1992). EEG mapping and
psychopharmacological studies with deribufylline in SDAT and MID. Biological Psychiatry.
32.668-681.
Sawada. H.• Udaka. F.• Kameyama. M.• Seriu. N.• Nishinaka. K.. Shindou. K.• Kodama. M.• Nishi-
tani. N .• & Okumiya. K. (1992). SPECT findings in Parkinson's disease associated with de-
mentia. Journal of Neurology. Neurosurgery. and Psychiatry. 55. 960-963.
Schneider. L.• & Sobin. P. (1992). Non-neuroleptic treatment of behavioral symptoms and agitation
in Alzheimer's disease and other dementias. Psychopharmacology Bulletin. 28. 71-79.
Schneider. L.• Pollock. V.• & Lyness. S. (1990). A metaanalysis of controlled trials of neuroleptic
treatment in dementia. Journal of the American Geriatric Association, 38. 553-563.
Shorvon. S. D.• Carney. M. W. P.• Chanarin. I.. & Reynolds. E. H. (1980). The neuropsychiatry of
megaloblastic anaemia. British Journal of Medicine. 281.1036-1038.
Shulman. R. (1967). Vitamin B12 deficiency and psychiatric illness. British Journal of Psychiatry.
113. 252-256.
Simpson. S .• & Foster. D. (1986). Improvement in organically disturbed behavior with trazodone
treatment. Journal of Clinical Psychiatry. 47. 191-193.
Skoog. I.. Nilsson. L.• Palmertz. B.• Andreasson. L.• & Svanborg. A. (1993). A population based study
of dementia in 85 year olds. New England Journal of Medicine. 328. 153-158.
Sneath. P.• Chanarin. I.. Hodkinson. H. M.• McPherson. C. K.. & Reynolds. E. H. (1973). Folate status
in a geriatric population and its relation to dementia. Age and Aging, 2, 177-182.
Dementia 145
Spignoli, G., Pedata, F., Giovanelli, 1., Banfi, S., Moroni, F., & Pepeu, G. (1986). Effect of oxiracetam
and piracetam on central cholinergic mechanisms and active avoidance acquisition. Clinical
Neuropharmacology, 9, S39-S47.
Strathmann, G. C. (1988). Possible neurotransmitter basis of behavioral changes in Alzheimer's dis-
ease. Annals of Neurology, 23, 616-620.
Swaab, D. F. (1991). Brain aging and Alzheimer's disease, "wear and tear" versus "use it or lose it."
Neurobiology of Aging, 12, 317-324.
Urakami, K., Shimomura, T., Ohshima, T., Okada, A., Adachi, Y., Takahashi, K., Asakura, M., & Ma-
tsumura, R (1993). Clinical effect of WEB 1881 (Nebracetam Fumurate) on patients with
dementia of the Alzheimer type and study of its clinical pharmacology. Clinical Neuro-
phamacology, 16,347-358.
Van der Cammen, T., Van Harskamp, F., Stronks, D., Pas schier, J., & Schudel, W. (1992). Value ofthe
mini-mental status examination and informants' data for the detection of dementia in geriatric
outpatients. Psychological Reports, 71, 1003-1009.
Zappoli, R, Ametoli, G., Paganini, M., Battaglia, A., Novellini, R, & Pamparana, F. (1991). Topo-
graphic bit-mapped event-related neurocognitive potentials and clinical status in patients
with primary presenile mental decline chronically treated with nicergoline. Current Thera-
peutic Research, 49, 1078-1097.
Zaudig, M. (1992). A new systematic method of measurement and diagnosis of "mild cognitive im-
pairment" and dementia according to ICD-10 and DSM-III-R criteria. International Psy-
chogeriatrics, 4, 203-239.
Zaudig, M., Mittelhammer, J., Hiller, W., Pauls, A .. & Thora, C. (1991). SIDAM-A structured inter-
view for the diagnosis of dementia of the Alzheimer type multi-infarct dementia, and demen-
tias of other etiology according to lCD-to and DSM-III-R. Psychological Medicine, 21, 225-236.
CHAPTER 8
Substance Abuse Disorders

TED D. NIRENBERG, EDITH S. LISANSKy-GOMBERG,
AND ToNY CELLUCCI
INTRODUCTION
In 1996, the first "baby boomers" turned fifty years of age. During the next two
decades as the baby boomers enter their 60s there will be an inexorable increase
in the elderly population. The proportion of people 65 years of age and older in
the general population is now approximately 13%. While the percentage of older
persons will clearly increase, the effect of this historical phenomenon on alcohol
and drug consumption among the older persons in future years remains to be
seen. Up to now, the data show that alcohol drinking in general, and heavy alco-
hol use in particular, declines with aging (Adams, Garry, Rhyne, Hunt. & Good-
win, 1990; Fillmore, 1987; Fillmore et 01.,1991; Glynn. Bouchard, LoCastro. &
Laird, 1985). There are differences within the older age group; for the "young el-
derly," those 60 to 74, there are modest changes, with some investigators report-
ing an increase in alcohol consumption during those years (Glynn et aI., 1985;
Gordon & Kannel, 1983). Beyond the age of 75, the drop in alcohol intake is con-
siderable, and there are fewer drinkers and fewer heavy drinkers in the older
years. It is believed that this decrease relates to increasing health problems and
to the increased proportion of women in older population subgroups. As is true
throughout the life span, older women drink less and abuse alcohol less than do
older men (E. S. L. Gomberg, 1995b). There are also geographic differences: the
prevalence of alcohol abuse ranges among older persons from 1.5 percent in
North Carolina to 3.7 percent in Baltimore (Helzer, Burnham, & McEvoy, 1991).
TED D. NIRENBERG • Department of Psychiatry and Human Behavior. and Center for Alcohol and Ad-
diction Studies. Brown University. and Department of Emergency Medicine, Rhode Island Hospital,
Providence, Rhode Island 02908. EDITH S.I.iSANSKY·GoMBERG • Alcohol Research Center, Depart-
ment of Psychology, University of Michigan, Ann Arbor, Michigan 48104. ToNY CELLUCCI • De-
partment of Psychology, Francis Marion University, Florence, South Carolina 29501-0547.
147
148 Ted D. Nirenberg et a1.
It is likely that with an increasing percentage of the population in the el-

derly group, there will be an increase in the number of elderly alcohol and
drug abusers. Relatively unstudied are decisions about alcohol and drug use
made by people as they age: some may choose to abstain, some to lower the
quantity and frequency, some may continue exactly as they have been doing
for decades, and others may increase the amount they use alcohol with the at-
tendant risk of problems. Such decisions are part of the aging process; for ex-
ample, older adults may need to decide whether to continue work or retire,
work part-time or start new careers, where to live, whether to travel, and
whether to become active in community institutions such as the church, elder
hostels, or volunteer organizations. In a word, decisions have to be made about
lifestyle, and decisions about alcohol and drug use are part of adaptation to ag-
ing. Health status, marital status, and income will play significant roles in
these decisions.
Over the life span, there are biological changes in the body's response to
different drugs. To learn about altered drug response in elderly persons, effects
of age on pharmacokinetics and pharmacodynamics need to be studied. Gam-
bert (1992) reviewed many of the physiological aspects of substance abuse in
older persons. Such changes associated with aging may heighten the impact of
alcohol and other drugs. For example, there is a decline in fluid relative to body
mass, so drinking results in a higher blood alcohol concentration and greater
CNS effects, including possible confusion and falls. Drug induced hypotension
also may be greater and more prolonged at this time of life, thus increasing risk
for cardiovascular problems. There is decreased respiratory functioning and ex-
ercise tolerance. In addition, neuroceptors may be more sensitive with advanc-
ing age, and the slow release of fat-soluble drugs into the bloodstream may
cause protracted effects (Miller, Belkin, & Gold. 1991). As a result, tolerance is
reduced in the elderly and withdrawal from dependence may be more severe.
Therefore, older individuals may find that amount of alcohol or other drugs that
they could easily tolerate when they were younger now results in adverse ef-
fects (Wartenberg & Nirenberg, 1994).
Elderly individuals also seem to be more susceptible to adverse drug reac-
tions (ADRs). ADRs can result from multiple drug therapy, drug overuse or mis-
use, slowing of drug metabolism or elimination, or age-related chronic diseases.
ADRs in older persons are more severe than among younger patients. Risk fac-
tors for ADRs include being female, living alone, multiple illnesses, multiple
drug intake, and poor nutritional status.
Although use and abuse of alcoholic beverages gets the lion's share of re-
search and media attention, use and abuse of substances other than alcohol are
relevant. Although illicit drugs ("street drugs") are not often used by the elderly,
the use and overuse of opiates in medical practice for pain control may be a con-
cern. Tobacco is frequently used and has been implicated in many health prob-
lems found among older persons. Over-the-counter (OTC) drugs and prescribed
medications have not been well researched. although there are significant prob-
lems associated with its use; for example, overprescribing ofbenzodiazepine, the
frequent use of sedative drugs in nursing homes, and in general the issue of drug
noncompliance among the elderly. Finally there is alcohol, a recreational sub-
stance easily available to adults, which may lead to significant problems for
Substance Abuse Disorders 149
many older persons. Abuse of alcoholic beverages by elderly persons has been
studied and described (Beresford & Gomberg, 1995; E. S. 1. Gomberg, 1982;
E. S. 1. Gomberg, 1990; Wartenberg & Nirenberg, 1994). First, a review of the
abuse of illicit drugs, tobacco, prescription and over-the-counter medications,
and alcohol is presented. This is followed by a discussion of assessment and
treatment implications.
Illicit Drugs
The use of drugs such as marijuana, heroin, and cocaine does occur among
some older individuals, but it is a limited phenomenon. Of interest, though, are
reports about a small group of opiate addicts who survive into old age (DesJar-
lais, Joseph, & Courtwright, 1985). Despite the widely held idea that addicts die
or "mature out," there are addicts who survive into old age. DesJarlais and his
colleagues (1985) described a group of heroin-dependent patients, 65 and older,
attending methadone maintenance facilities. These long-term addicts survived
by avoiding violence, using clean needles during IV use, and apparently being
able to hold some drug supply in reserve. They also tend to avoid other drugs
such as alcohol. Although we find such survivors among the heroin-dependent,
it is less likely that we will find them among cocaine- or crack-dependent
groups. In Michigan (Michigan Department of Public Health, 1994), treatment
admissions for heroin-dependent people is 6% for those less than 60 years of
age and 3% for those 60 years and older. Treatment admissions for those de-
pendent on cocaine or crack is 18% for those under 60 and 2% of those 60 and
older. In addition, opium smoking among older people is seen in some Oriental
cultures. With increased immigration to the United States from Southeast Asia,
this phenomenon may increase.
Tobacco
Men are more likely to be tobacco smokers than are women, although the
gender gap has narrowed in the past three decades. The National Center for
Health Statistics (1986) reported that in 1965. 28.5% of older men and 9.6% of
older women were smokers. By 1985, percentages had become 19.6% for men
and 13.5% for women. It is striking that the proportion of older men who smoke
has decreased while the proportion of older women who smoke has increased.
Among women aged 20 to 64. the percentage of current smokers has been drop-
ping (not true among adolescent girls; Berman & Gritz. 1993). One may specu-
late that the female cohort that began smoking during and immediately after
World War II is the current older population group. The price of such "lib-
erated" behavior has been high: In the 1960s, female deaths from lung cancer
began to rise. Since 1985, lung cancer has surpassed breast cancer as the chief
cause of cancer death among women. However. it is difficult to establish the
role of tobacco in the health status of older people. A study of drug metabolism
(Sellers, Frecker, & Romach, 1982) concluded that the effects of aging, smoking,
and drinking are confounded and difficult to disentangle.
Prescribed and Nonprescribed Psychoactive Drugs
In terms of prevalence, use of prescribed psychoactive drugs (e.g., seda-

tives, antidepressants, stimulants, anxiolytics) probably involves the greatest
number of older persons. Although the elderly represent only approximately
13% of the general population, estimates are that they receive at least one third
of all prescriptions. While such prescriptions include antibiotics, diuretics, car-
diovascular medication, and analgesics, they also include significant amounts
of psychoactive drugs (E. S. L. Gomberg, 1987).
Although treatment facilities report some elderly patients with drug-asso-
ciated problems and dependence on prescribed psychoactive drugs, the issue
has not evoked much interest among researchers, clinicians, or legislators.
Older persons frequently associate their intake of psychoactive drugs with
problems such as insomnia or depression and almost half of those taking such
medication report that they could not perform their daily activities without the
medication (Prentice, 1979). It is difficult to define what abuse of prescribed
psychoactive drugs is. Kleber (1990) has differentiated primary low-dosage de-
pendency, primary high-dosage dependency, and secondary dependency as pat-
terns seen with benzodiazepine use. Individuals may use benzodiazepines in
usually prescribed low therapeutic doses, in prescribed high doses, or in mul-
tiple drug use, frequently involving alcohol, to achieve a "high" or some form
of self-prescribed release. Use in high doses or in multiple drug use usually
involves withdrawal symptoms when drug use is terminated. Another classi-
fication of prescribed psychoactive drug use distinguishes appropriate use, un-
intentional misuse, and purposeful misuse.
There are a number of issues that may be raised about older individuals' use
of prescribed psychoactive medication. First, questions have been raised about
use of such medications in nursing homes. How certain can we be that medica-
tion given to ensure docility and compliance of the patient is given for that indi-
vidual's own benefit? Second, as noted earlier, what is the risk of adverse drug
reactions (ADRs)? It is estimated that the incidence of ADRs is two to three times
more frequent among older patients. Studies suggest that several drugs (Le.,
dioxin, diuretics, aspirin, cytoxins, nonsteroidal anti-inflammatory drugs, and
psychotropics) in particular should be monitored for ADRs. ADRs may be a con-
sequence of multiple drug therapies, drug interactions, changes in drug metabo-
lism and elimination with age, noncompliance with prescribed use, incompatible
food-drug combinations, or alcohol intake combined with medication use.
Noncompliance with prescribed drug regimens is an interesting and under-
studied phenomenon. In all age groups, noncompliance in use of prescribed
medication is noted, but it commands more attention when manifested by older
persons. Although noncompliance with medication by elderly persons is often
attributed to cognitive impairment, it appears to be more complex than simple
memory failure. Perhaps rebellion against authority or need for autonomy is in-
volved. Noncompliance includes the following: (1) not obtaining the prescribed
drug, possibly because of limited financial resources; (2) not completing the
prescribed course of medication, often because of side effects or because the pa-
tient feels better; (3) incorrect dosage (more or less than prescribed); (4) im-
proper timing or sequencing of medication; (5) combining the prescribed
medication with OTC drugs; (6) sharing medications: using medications pre-
scribed for another person; and (7) stockpiling or hoarding medications.
In a pilot study of patient medication compliance in a veterans hospital,
male outpatients with a mean age of 58 reported stockpiling or hoarding med-
ication as their major noncompliant behavior (E. S. L. Gomberg, Hsieh, &
Adams, 1990). As pointed out by the investigators, such hoarding might well
be construed as adaptive behavior for a low-income group threatened by bud-
get cuts.
A comparison of different age groups in drug-associated emergencies is re-
vealing. In the 43 major American cities for which emergency department data
are included in the Drug Abuse Warning Network (Annual Medical Examiner
Data, 1995), younger patients were more likely to die in emergencies relating
to illicit drugs like cocaine than were older patients. Of those for whom the
"drug mention" was cocaine, 74% were between the ages of 26 and 44. Among
persons 55 and older, the most frequent "drug mentions" included nonbarbitu-
rate and barbiturate sedatives, nonnarcotic analgesics, antidepressants, and
tranquilizers. Also frequent were emergencies of older persons involving the
use of such over-the-counter drugs as diphenhydramine.
Examination of the gender patterns in drug abuse deaths reported by the
Drug Abuse Warning Network indicates that the proportion of drug abuse
deaths reported for women in the 55 and older group is twice that for men in
the same group: 6.5% for the men, 13.3% for women. This is striking, consid-
ering that men use emergency departments three times more frequently than do
women. This gender difference is primarily a White phenomenon. Blacks show
the same proportion of drug abuse deaths for men and women and Hispanics
show twice as many for men as for women.
Nonprescription drugs (OTC) also are frequently used and abused by the
older persons; in fact, two thirds of persons greater than 60 years of age take at
least one OTC drug daily (Abrams & Alexopoulous, 1988). The most commonly
purchased nonprescription drugs are analgesics, nutritional supplements (e.g.,
vitamins), antacids, and laxatives. The Food and Drug Administration has sug-
gested special labeling for persons over 65 but the general response to age-
related labeling on OTC drugs has been negative; the consensus is that labeling
by specific medical conditions and symptoms is preferable. While generally
viewed as less dangerous than prescribed medications, the OTC drugs are fre-
quently misused-either underutilized, overutilized, or negatively interacting
with another drug.
Alcohol
Although a large percentage of older people continue to drink moderately

(and some, heavily), by and large the percentage of elderly who drink and the
amount they drink diminish with age. There are, however, a number of recent
reports that suggest that among some older groups, alcohol consumption re-
mains steady or even increases (Eaton, Kramer, & Anthony, 1989; Gordon &
Kannel, 1983; Huffine, Folkman, & Lazarus, 1989). Community survey findings
vary with the age range studied, the gender ratio in the population, and the
geographic site. There is some evidence that after declining, the rate of alcohol
abuse among older males rises (Eaton et aI., 1989); this confirms an early epi-
demiological study that reported a jump in the proportion of alcoholics among
men in their seventies (Bailey, Haberman, & Alksne, 1965).
In all age groups, women tend to drink less than men, and it is apparently
true with older cohorts. As noted earlier, there also are geographic differences
among samples: whereas prevalence of alcohol abuse was reported as 1.5% in
the Piedmont area of North Carolina, it was 3.7% in Baltimore (Helzer et al.,
1991). In California, 8.2% ofrespondents aged 65 to 74, and 6.4% aged 75 and
over were "heavy drinkers" (Molgard, Nakamura, Stanford, Peddecord. & Mor-
ton, 1990). Retirement communities have reported a high prevalence (Le., 20%
or more) of heavy drinking (Alexander & Duff, 1988; Paganini-Hill, Ross, & Hen-
derson, 1986). Explanations oflowered alcohol consumption among older per-
sons in terms of historical experience with Prohibition and the Depression are
increasingly inappropriate as this generation begins to die. Also, such explana-
tions have always been limited by the fact that many western countries. which
did not experiment with Prohibition, show similar rates and patterns of drink-
ing by older age groups.
It is difficult to estimate the extent of alcohol abuse and dependence. Com-
munity surveys and hospital interviews produce some estimates ranging as
high as 25% of the elderly. As always, it is a matter of definition, with some in-
vestigators addressing heavy drinking, others alcohol-associated problems, and
still others clinically defined abuse and dependence. Helzer and his colleagues
(1991) have pointed out that a much higher percentage of older people had less
severe alcohol problems in the Epidemiologic Catchment Area data. When esti-
mates of heavy or problem drinking are made, particularly in retirement com-
munities, prevalence ranges from 20% (Alexander & Duff, 1988) to 31 % of men
and 22% of women 60 years of age and older (Paganini-Hill et a1., 1986).
Clearly, alcohol use cannot be written off as irrelevant to the older age group
simply because many of the heavy drinkers or problem drinkers have died or
"matured out" of such behavior.
By and large, the patterns of drinking and alcohol-related problems do not
seem very different for young and older problem drinkers (DeHart & Hoffman,
1995). Older problem drinkers are less likely to have work-associated problems,
but they may have more alcohol-related health problems, more accidents, more
concern about finances. and possibly more likelihood of binge drinking. Varia-
tions within the population of older problem drinkers, who range from unem-
ployed, homeless Skid Row men (Rubington, 1982) to retired executives of
corporations, suggest that the private versus public aspects of drinking, the bev-
erages consumed, and the consequent difficulties vary widely.
Information specifically about elderly female problem drinkers is limited,
but a recent report comparing problem drinking elderly men and women (E. S. L.
Gomberg, 1995b) shows a remarkable consistency. The women, however, re-
ported more marital disruption, although in this age group, it is more likely that
widowhood is a major form of marital disruption. When queried about onset of
their alcohol problem, more than a third of the women reported onset within
the past ten years, compared with only 4% of the men studied. Women also are
admitted to treatment programs with shorter duration of problem drinking than
men in all age groups. Heavy or problem drinking by a spouse or significant

other is, again, reported by more women than men-true of all age groups stud-
ied. Women report more drinking at home and men more drinking in public
places. And, finally, as is true in all age comparisons, elderly women are more
likely to report heavy use and dependency on prescribed psychoactive drugs
than are men.
A comparison of black and white elderly alcoholic men in treatment shows
some interesting differences (E. S. L. Gomberg & Nelson, 1995). Although
drawn from the same clinical sources, the black patients had significantly less
education and lower occupational status and income. In terms of drinking pat-
terns, the black patients drank larger quantities, preferred distilled beverages,
and were more likely to drink outdoors or in public places. Consequences of
heavy drinking that were health-related were reported more often by black pa-
tients. Black men also reported more difficulty in the workplace and with the
police. A regression model for social and community drinking consequences
suggested that educational achievement, lifetime daily drinking average, drink-
ing in public, and race had the greatest relevance. It is of interest to note that
"objections from family members" was an area of similarity between elderly
black and white men.
There is a fair amount of published literature on neuropsychological or
cognitive loss as a consequence of heavy drinking. Deficits have been studied
in terms of functions impaired, gender differences, the relationship to age,
and heavy alcohol use. A "premature aging" hypothesis posited premature
senescence brought on by heavy drinking; the hypothesis said little about el-
derly drinkers, but instead focused on middle-aged alcohol abusers. Cognitive
impairment studies tend to focus on such specific functions as short-term
memory and the ability to process new information. A significant clinical
problem is the reversibility of cognitive loss; most clinicians agree that el-
derly alcohol abusers will, given sufficient time, regain most of their lost
functioning. Older persons need more time than younger problem drinkers for
such reversal to occur. However, some alcohol-dependent patients recovering
from classic Wernicke's encephalopathy exhibit the selective memory distur-
bance of Korsakoff's amnestic syndrome, which involves long-term deficits in
anterograde and retrograde memory and apathy (Kopelman, 1995; Victor,
Adams & Collins, 1989).
Finally, there is a neglected, understudied group of elderly problem drink-
ers. Once called the chronic drunkenness offenders, this Skid Row group has
become merged with the general homeless population. In past studies, a dis-
proportionately high percentage of arrests for public intoxication was noted
among men 60 years of age and older (Epstein, Mills & Simon, 1970). There
have been significant changes since a Supreme Court decision of the 1960s in
which arrests for public drunkenness were ruled a violation of rights under the
8th amendment of the Bill of Rights (i.e., cruel and unusual punishment for the
disease of alcoholism). There has been a shift toward more available detoxifi-
cation sites for this group (Rubington, 1982); unfortunately, without also pro-
viding rehabilitation, the detoxification sites have turned into the revolving
door that jails once represented. This subgroup of elderly alcohol abusers still
deserves study and rehabilitation effort.
154 Ted D. Nirenberg et 01.
Age of Onset
Clinical observations have led to classification of elderly problem drinkers

and alcoholics on the basis of whether alcohol problems began earlier or later
in their life: early versus late onset (Atkinson. 'furner, Kofoed, & Tolson, 1985;
Zimberg, 1974). The age cutoff used to delimit late-onset problem drinking
typically ranges from 40 to 60 years (Atkinson, 1984). Late-onset problem
drinking has been reported to account for between 28% and 40% of elderly
problem drinkers found in clinical samples (Atkinson et a!., 1985; Rosin &
Glatt, 1971; Zimberg, 1974). There is disagreement among researchers and
clinicians about the specifics of this classification, in particular, the age that
should be used to define late onset. If one uses 40 years of age as the cutoff of
late onset, we would be including problem drinkers with a history of 25 or 30
years of alcohol abuse. Other efforts at classification attempt to capture more
variation in drinking patterns by including categories for drinkers whose prob-
lems are transient or intermittent throughout the individual's lifetime, or that
may vary over time with respect to the quantity and consequences of drinking
(E. S. L. Gomberg, 1982; Dunham, 1981). An alternative definition oflate onset
views the problem drinking developed relatively recently as linked to adapta-
tions and difficulties related to aging. Gomberg (1990) defined recent onset as
the preferable term, the criterion being the beginning of alcohol-related prob-
lems within the past 10 years.
The epidemiological literature on risk factors predicting vulnerability to
late-onset alcohol problems is limited (Douglas, 1984). Generally, late-onset pa-
tients are seen as having less family history of alcoholism and greater psycho-
logical resources (Atkinson, Tolson, & Turner, 1990). Some evidence suggests
that late-onset alcohol problems are a maladaptive response to common per-
sonal, social, and environmental stressors that are correlates of the aging
process (Atkinson. 1984; Finlayson, Hurt, Davis & Morse, 1988; Rosin & Glatt,
1971; Zimberg, 1974). Schonfeld and Dupree (1991) compared early- versus
late-onset alcohol abusers, matched for age and gender. Although late-onset pa-
tients were more stable in terms of residence, both groups experienced the
losses and stresses associated with aging, including diminished social support,
loneliness, and feelings of depression. Zimberg (1995) has argued that although
reactive drinking in response to the stressors of aging describes the late-onset al-
coholic, such events also may prolong drinking problems in those patients with
early-onset alcohol problems.
DIAGNOSIS
Substance-related disorders are classified by the Diagnostic and Statisti-

cal Manual of Mental Disorders, 4th edition (DSM-IV; American Psychiatric
Association, 1994) into two groups: (1) Substance Use Disorders which in-
clude Substance Dependence and Substance Abuse and (2) Substance-
Induced (S-I) disorders which include Substance Intoxication, Substance
Withdrawal, S-I Delirium, S-I Persisting Amnestic Disorder, S-I Mood Disor-
der, S-I Anxiety Disorder, S-I Sexual Dysfunction, and S-I Sleep Disorder.
The general criteria for diagnosis of Substance Dependence include toler-

ance; withdrawal; substance use in larger amounts or over a longer period of
time than was intended; persistent desire or unsuccessful efforts to cut down
or control substance use; much time spent in activities necessary to obtain or
use the substance or recover from its effects; social, occupational, or recre-
ational activities given up or reduced because of substance use; and contin-
ued use despite knowledge of having a persistent or recurrent physical or
psychological problem that is likely to have been caused or exacerbated by
the substance. Criteria for Substance Abuse include recurrent substance use
resulting in a failure to fulfill major role obligations at work, school, or
home; recurrent substance use in situations in which it is physically haz-
ardous; recurrent substance-related legal problems; and continued substance
use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of the substance. The S-I disorders,
though frequently overlooked by clinicians, are highly relevant to the elderly
patient. Although older persons may not exactly fit the criteria of depen-
dence or abuse, their substance use may be the cause or one of the causes of
another disorder.
Relevance of the DSM-IV diagnostic criteria to the older persons is ques-
tionable since the criteria were based primarily on younger age groups. Indeed,
some of the criteria may not be relevant to many older individuals (King, Van
Hasselt, Segal & Hersen, 1994). For some older people, absence of standard
daily obligations (e.g., work, community service, school, and child rearing) and
physical and medical problems may obscure signs of substance intoxication
and withdrawal. Therefore, reliance on such criteria may lead to misdiagnosis
and probably explains the apparent underdiagnosis and inconsistencies in re-
ported prevalence rates. To address this problem, it has been suggested that the
weight of these criteria for older people be changed (Atkinson, 1990) or that
there be more focus on the elderly person's pattern of use.
Many of the assessment instruments that have been developed have been
standardized on younger age groups. Only recently has the validity of these
instruments for use with older persons been examined. For instance, Jones,
Lindsey, Yount, Soltys, and Farani-Enayat (1993) examined the validity ofthe
CAGE questionnaire (Ewing, 1984) and the Michigan Alcoholism Screening
Test (MAST; Selzer, 1971) for patients 65 years of age or older. They found, by
using the alcohol module of the Revised Diagnostic Interview Schedule (DIS-
III-R) as the "gold standard," that the CAGE was more effective than the MAST
in identifying elderly medical outpatients with alcohol abuse or dependence.
However, the finding that both the CAGE and the MAST had low sensitivities
at the conventional screening cutoffs suggests that cutoffs should be modified
for older persons. Willenbring, Christensen, Spring, and Rasmussen (1987),
however, in a comparison of four versions of the MAST used with an elderly
sample found that the regular MAST had excellent sensitivity. F. C. Blow and
colleagues (1992) introduced a geriatric version of the MAST. Although the
scale needs further study, it is one of the first attempts to devise a screening tool
that takes into account the unique characteristics of the elderly. Similarly,
Finney, Moos, and Brennan (1991) developed the Drinking Problems Index, a
17-item test that assesses older persons' drinking problems over the past year. It
includes such items as being intoxicated or drunk, feeling confused after drink-
ing, feeling isolated from others due to drinking, and falling or having an acci-
dent because of drinking.
Further development and refinement of existing instruments that will be
sensitive to older persons are warranted. Graham (1984) argues that older indi-
viduals may have memory impairments that affect the validity of self-reported
alcohol use and abuse. Although memory impairment is clearly a correlate of
severe dementia, very little is known about implications of moderate or mild
dementia on self-reports (Fogel, Furino, & Gottlieb, 1990). Selecting appropriate
measures and employing multiple measures is essential to ensure the validity
of self-reports (Babor, Stevens, & Marlatt, 1987; Carp, 1989; Tucker, Gavornik,
Vuchinich, Rudd, & Harris, 1989; Werch, 1989). Procedures should minimize
response bias on alcohol and drug measures that are due to memory loss, for ex-
ample, avoiding items that require mental averaging and increasing use of
fixed-response choices (National Institute on Alcohol Abuse and Alcoholism,
1990; Babor et aI., 1987).
In addition to self-report measures, investigators should 0) obtain collateral
reports (Le., from caregivers, spouse, children, and friends), (2) examine previ-
ous medical records, (3) use breath alcohol tests and drugs toxicology screens,
(4) examine biochemical markers of alcohol abuse such as gama-glutamyl
transpeptidase, and (5) assess medical conditions and psychosocial problems
that might be correlated with substance abuse. Much of the literature on sub-
stance abuse and older persons discusses the need for treatment to take into ac-
count the unique biological and psychosocial factors associated with aging.
Clearly, treatment recommendations and planning should be based on a com-
prehensive assessment, with a continuum of services available for both sub-
stance abuse and dependence.
TREATMENT
Despite prevalence data reviewed earlier, older persons are underrepre-

sented in treatment settings (Lawson, 1989). The diagnosis of substance abuse
problems reported by clinicians is less than prevalence rates as determined by
the Epidemiologic Catchment area study (Miller et al., 1991). Moos, Mertens,
and Brennan (1993) found that older inpatients were less likely to be referred
for rehabilitation, which is consistent with earlier studies suggesting under-
diagnosis. For many reasons, older individuals also seek outpatient mental
health services, including alcohol treatment, less readily than younger persons
(Brennan & Moos, 1991; Carstensen, Rychtarik, & Prue, 1985). Generally, help
seeking among older persons is more prevalent if they are female, have more
negative life events and chronic stressors, report fewer friends who approve of
drinking, use more avoidant coping, and have a history of prior use of treatment
(Brennan, Moos, & Mertens, 1994; Finney & Moos, 1995).
There are a number of barriers that may prevent older adults from obtain-
ing help (Lawson, 1989; Zimberg, 1995). First, there are differences in presen-
tation and, as noted earlier, difficulties in diagnosis. Health care professionals
often lack training and knowledge about substance abuse, especially patterns of
substance abuse in this population (Lewis, 1995). There are also such patient
characteristics as long-standing denial accompanied by severe medical compli-
cations. Medical and social problems of the elderly are often inappropriately
seen as simply part of the aging process. Certainly, attitudes that substance
abuse among older patients does not warrant or respond to treatment efforts re-
flect ageism. However, there also are practical problems involved including
lack of financial resources and insurance, or limited transportation. Lawson
(1989) has argued that older persons should be treated in the settings they fre-
quent (e.g., senior centers, primary care facilities), and Zimberg (1995) per-
ceives lack of treatment models alternative to traditional and 12-step programs
as a limitation. There is a need for further research on possible impediments to
engaging older problem drinkers in treatment.
There also has been little empirical study of the effectiveness of sub-
stance abuse treatment approaches with elderly patients, and much of the
available information is retrospective (Institute of Medicine, 1990). Early
studies (e.g., Janik & Dunham, 1983) found treatment effects for older patients
to be comparable with those of younger patients in traditional programs.
However, other clinical investigators have argued for programs specific to
older people (Dupree, Broskowski, & Schonfeld, 1984; Zimberg, 1974, 1995).
In a systematic examination of this issue, Kofoed, Tolson, Atkinson, Toth, and
Turner (1987) compared use of elder-specific peer groups with a control group
of patients seen in typical mixed-age outpatient groups. Those alcoholics
(mean age 60.2 years) who received elder-specific treatment were more likely
to remain in treatment despite lapses and were less likely to be drinking at
discharge. A follow-up study of the same program revealed that 57% of pa-
tients completed one year of elder-specific outpatient treatment, in marked
contrast to the 27% completion rate typical of many VA programs (Atkinson,
Tolson, & Turner, 1993).
Krashner, Rodell, Ogden, Guggenheim, and Karson (1992) similarly com-
pared an "older alcohol rehabilitation" (OAR) program to traditional treatment
in a VA setting. The study population, described as mostly unmarried, white,
with less than a high school education, and relatively poor, was randomly as-
signed to the two programs. OAR patients resided on a separate unit with spe-
cialized staff. Peer relationships and use of reminiscence therapy were
emphasized, as opposed to traditional confrontation and problem solving. At a
1-year follow-up, OAR patients were significantly more likely to report absti-
nence and this difference increased with patient age.
Although these data suggest that there is therapeutic value in special pro-
gramming for elders, findings from the National Drug and Alcoholism Treat-
ment Unit survey indicated that such efforts are relatively rare. Only 9% of
NIDA/NIAAA treatment units in 1982 reported offering specialized programs
for elderly patients, with the proportion declining to 8% in 1987 (Institute of
Medicine, 1990). Similarly, Nirenberg and Maisto (1990) in a survey of VA in-
patient alcohol treatment programs found that only 3% of program directors re-
ported providing special interventions in terms of minority issues or special
populations.
158 Ted D. Nirenberg et al.
Detoxification, Medical Complications, and Medication
In evaluating the need for detoxification, the patient's prior withdrawal ex-
perience, level of tolerance. and clinical status should be considered (Warten-
berg & Nirenberg, 1995). The older patient may have fewer hyperautonomic
signs, but may be at greater risk for associated complications. A recent study of
withdrawal distress revealed that elderly patients experienced significantly
more withdrawal symptoms for a longer time despite similar drinking histories
prior to admission (Brower, Mudd, Blow, Young, & Hall, 1994). They also were
more likely to experience cognitive impairment, daytime sleepiness, weakness,
and high blood pressure. These latter symptoms may reflect underlying medical
conditions. Wartenberg and Nirenberg (1995) generally recommend that the el-
derly patient in withdrawal be medically monitored. Treatment of acute with-
drawal may involve administration of a short-acting benzodiazepine, usually
lorazepam. The dose may need to be modified and the detoxification period ex-
tended for the elderly patient. Nutritional status should be assessed, with thi-
amine typically administered to prevent amnestic syndrome.
The elderly patient is more likely to have medical problems because of his or
her association with chronic dependence and because of age-prevalent illnesses.
Solomon, Manepalli. Ireland, and Mahon (1993) described the many medical con-
sequences of alcoholism in the elderly, including peripheral neuropathy. acute
and chronic pancreatitis, alcoholic liver disease. gastrointestinal bleeding, cardio-
myopathy, cancer, and electrolyte and metabolic disturbances. An early review of
the medical records of elderly patients with alcoholism found elevated rates of
liver disease, peptic ulcers, psoriasis, and pulmonary disease (Hurt, Finlayson, &
Morse, 1988). Gambert (1992) also listed age-prevalent diseases or conditions that
may coexist with and are exacerbated by substance abuse. These include anemia,
hypertension. gout. arrhythmias, diabetes, osteoporosis, dementia, and inconti-
nence. Medical problems also may be caused by the interaction of alcohol and
OTC medications (Lawson, 1989). A thorough evaluation of such medical prob-
lems is an important aspect of treatment, in that regaining and improving health
status is often a goal the elderly substance abuser is motivated to work toward.
Certain medications (e.g., antabuse, naltrexone) are increasingly being rec-
ognized as having a legitimate role in substance abuse treatment, but little is
known about their efficacy among elderly patients. In his review, Gorelick
(1993) could not locate any medication trials that explicitly addressed pharma-
cological treatment of alcoholism in this population. While antabuse may be
helpful in selected married, middle-aged men (Azrin, Sisson, Meyers, & Godley,
1982), it may be contraindicated in some medically compromised elderly pa-
tients. Zimberg (1995) also has discussed the importance of using antidepres-
sants in treating depressed elderly patients who are also substance abusers.
Psychosocial Treatment
Evidence from general population surveys for the role of psychosocial

stressors in development of excessive drinking among older persons has been
conflicting (Jennison, 1992; Welte & Mirand, 1993). Jennison (1992) reported
that subjects 60 years of age or above who experienced significant losses (e.g.,
divorce, lost employment, relative hospitalized or disabled) were more likely to
drink excessively, although supportive resources (e.g., friends, family, church)
had a stress buffering effect. However, Welte and Mirand (1993) did not find a
relationship between acute stress and heavy drinking among older persons, al-
though chronic stress did predict more drinking consequences and depen-
dence. Krause (1995) found that drinking in later life tends to be a lifestyle
factor rather than a coping response, with heavy drinking exacerbating the ef-
fect of salient role stressors on depressive symptoms. In a community hospital
study of elderly inpatients on a general medical ward, neither alcohol con-
sumption nor alcohol problems were found to be associated with the number of
stressful life events reported (Laforge, Nirenberg, Lewis, & Murphy, 1993).
Yet, many elderly substance abuse patients present with recent psychoso-
cial issues, and such events often are considered as contributing to late-onset
substance abuse. For example, in an early study 81 % of patients with late-
onset alcoholism reported such life stressors as retirement, death of a spouse
or relative, family conflict. and physical health problems (Finlayson et 01.,
1988). Five of seven (71 %) elderly late-onset alcohol patients in a VA sample
were found to have recent difficulties adjusting to retirement (Carstensen et
01., 1985). Lawson (1989) has discussed the losses and other adjustments as-
sociated with aging as risk factors for substance abuse, although obviously not
all stressed older persons become alcohol abusers. It may be that the clinically
observed association between stressful life events and late-onset drinking
problems is simply a reflection of the high rate of stressful events for the el-
derly population in general.
Considerable information has been generated about the personal character-
istics, life circumstances, and coping responses of older individuals with drink-
ing problems through the ongoing research program of Rudolf Moos and his
colleagues (Brennan & Moos, 1995; Brennan et 01., 1994; Schutte, Brennan &
Moos, 1994). A detailed assessment of selected elderly patients at several large
medical facilities was used to obtain information about drinking status, health,
and other life circumstances. The majority of the sample were white and well
educated. Subjects were classified based on their Drinking Problem Index
scores (Finney et 01., 1991) as either remitted problem drinkers, problem
drinkers, or nonproblem drinkers. Problem drinkers reported more alcohol con-
sumption and an average of five current drinking problems. In addition, they re-
ported more negative life events and chronic stressors such as home difficulties,
financial stress, and interpersonal conflict. Their life contexts involved fewer
material resources and less social support from family and friends. Although
problem drinkers and nonproblem drinkers reported similar types of stressors
and coping strategies, the problem drinkers were more likely to react to stress
with resignation and to use avoidance or emotion-focused coping. Not surpris-
ingly, those elders in more stressful life contexts with fewer social resources
had greater alcohol consumption, more drinking problems, and were more de-
pressed. Moreover, greater use of avoidance coping was linked to chronic stress,
fewer social resources, and eventually poorer functioning.
Importantly, personal and environmental risk factors also were found to
interact. Heavier drinkers generally increased their consumption when they
experienced more negative life events and, unlike lighter drinkers, did not re-
duce their consumption with new health events. Also, as with younger patients,
association with peers who approve of drinking may sustain problem drinking
status. This research suggests that intervention efforts should assess various do-
mains of life functioning and aim for improved life circumstances, increased
social resources, and adaptive coping skills.
Not all drinking problems among these older persons were stable; a sizable
portion (approximately 20%-25%) of older individuals changed their drinking
problem status over time. Most (70%) of those identified as remitted at 1 year
maintained this status at a 4-year follow-up. A greater proportion of late-onset, as
compared to early-onset, drinkers achieved stable remission. Patients who remit-
ted generally included those with less consumption, fewer drinking problems, less
spouse support, fewer friends who approved of drinking, more personal distress,
and were more likely to have sought professional help. Correlates of remission also
differed for early-onset versus late-onset problem drinkers with remission in the
former group mostly associated with help-seeking efforts. Symptoms and life func-
tioning of remitted drinkers relative to nonproblem drinkers continued to be poor
early in their course of recovery, but were improved at the later follow-up, even
though some deficits (e.g., marital strain and physical health) remained. This con-
tinuing research effort provides the clinician with a rich picture of the context, in-
teractive nature, and course of late-life drinking problems.
Behavioral 7reatment
To date, few treatment approaches have been evaluated for elderly sub-
stance abusers. Among these approaches is cognitive-behavioral skill training.
A follow-up study of older patients treated in the alcohol treatment program in
the Jackson Veterans Administration Hospital, which employed a social learn-
ing view of substance abuse, showed that many elderly responded positively
to this approach (Carstensen et a1., 1985). In addition to medical attention, pa-
tients received alcohol education and counseling, which included training in
self-management and problem-solving skills. Structured interviews with pa-
tients and collaterals revealed that 50% of these male veterans (aged 65-70) had
successfully maintained abstinence for 2 to 3 years, with an additional 12% re-
porting significantly decreased intake.
The Gerontology Alcohol Project (GAP) in Florida is perhaps the most fre-
quently cited reference (Dupree et a1., 1984) of behavioral treatment. This pilot
day treatment program involved intensive assessment of 48 late-onset alcohol
abusers (mean age 64) and a self-management treatment approach based on
functional analysis of drinking, skill acquisition, and reestablishment of social
support networks. Most of the subjects were either widowed, separated, or di-
vorced, with generally poor social networks. In a community center for the
aged, treatment using manuals was provided in a group format. Treatment con-
sisted of various modules (e.g., analysis of the antecedents and consequences of
drinking, self-management of high-risk situations, alcohol education, problem
solving, building a social support network). In the original report, 17 patients
chose abstinence and another 7 patients a treatment goal of limited, responsible
drinking. Program success was conservatively defined as not violating these
goals throughout the 12-month follow-up, with those lost in follow-up consid-
ered failures. Nevertheless, the program was 74% successful. There also was
significant improvement in collateral ratings, community adjustment scores,
and size ofthe patients' social networks. Of the few patients who slipped, none
returned to their earlier abusive drinking pattern.
These reports support use of cognitive-behavioral treatment. However, the
data are limited by the small sample sizes and by the problem of high treatment
dropout rates. Moreover, in these studies there was little emphasis on cognitive
intervention per se, although Glatz (1995) recently has suggested a method of
applying the cognitive treatment model (see also Beck, Wright, Newman, &
Liese, 1993) to the substance-abusing elderly.
Group Treatment
A second model that has been successfully employed with older substance
abusers is supportive, social group treatment (Atkinson, 1995). There are many
advantages of group treatment for this population, including counteracting feel-
ings of loneliness and isolation, peer modeling and support, and opportunities
to draw on the life experiences and leadership skills of the elderly. Lawson
(1989) succinctly states that an important resource for older persons is older
individuals themselves, and he discussed the need for therapists who gen-
uinely like working with this population. Such groups have been described as
positive and task oriented with the goal of making life more meaningful and en-
joyable. Psychosocial themes explored in these groups include accepting the
losses involved in aging, dealing with feelings of hopelessness and grief, con-
fronting and solving life problems, and reviewing one's life or reminiscing.
Physical fitness and social activities also may be included.
Zimberg (1995) suggested, for example, dividing weekly 2-hour group ses-
sions into an informal socializing period with refreshments and a problem-solv-
ing time. While patients are told that they have a drinking problem that is
probably related to the difficulties they are having in life adjustment, this is
only one of the problem areas discussed. Zimberg has found that many elderly
alcoholics are more comfortable in senior-oriented programs, although some
may accept alcohol-specific treatment with the addition of such a psychosocial
group focusing on the stresses of aging. A small survey of recovering elderly pa-
tients (Johnson, 1989) indicated that group treatment, especially elder-specific
groups, was preferred by patients, who also made further recommendations to
use large print materials and allow ample time for seniors to complete sug-
gested projects. Such programs also may draw on community resources such as
needed social services (e.g., home health and meals-an-wheels).
Much of the evaluation data supporting this approach have arisen from
comparisons of elder-specific to mainstream treatment (Atkinson et al., 1993;
Kofoed et al., 1987). Kofoed and colleagues (1987) reported on a sample of el-
derly (aged 55 to 76 years) in terms of program completion, known relapses,
and successful treatment after relapses. The groups (containing 6 to 10 patients)
met weekly in the afternoon, used a slower pace, and emphasized socialization
and support versus confrontation. Sociotherapeutic processes included social
bonding, shared reminiscences, alcoholism-related information, and efforts to
resolve life problems. Abstinence was the stated goal for all patients. Seven of
nine relapsing patients were successfully treated with only two patients drink-
ing at discharge. In a 5-year study of the same program. 117 (57%) of 205 VA pa-
tients completed 1 year of outpatient treatment; this presumably translated into
improved drinking status and psychological functioning (Atkinson et a1., 1993).
Although these reports have a different focus (e.g., predicting treatment
compliance), the data have been used to support the use of such groups. More
outcome information is needed on the impact of social treatment groups on
other areas of life health besides drinking, and on comparisons with commu-
nity samples. It is not advantageous to mix severely dependent and alcohol
abusing patients who have different treatment perceptions and goals. Moreover,
as yet no studies have compared supportive social groups to cognitive behav-
ioral treatment (Atkinson, 1995).
Community Outreach
Community outreach programs are a third alternative for providing needed
services to patients who may be unable or reluctant to leave their home. Gra-
ham and colleagues (1995) have recently published a report of their experience
with the Community Older Persons Alcohol project in Toronto. This innova-
tive, holistic program provided individualized assistance to seniors so as to
maintain them in their homes and improve physical and emotional well-being
(including a reduction or elimination of alcohol or other drug dependence or
both). The intervention process included assessment, active treatment, and
maintenance phases. A problem-centered, nonconfrontational approach was
adopted using collaborative goal setting, counseling and other direct services,
and case management. Monitoring data were reported on 56 treated clients
(mean age 64). Most of the clients were drinking daily or nearly every day, al-
though maximum average consumption was relatively low (i.e., 38% drinking
five or more drinks per day). Use of psychoactive prescription drugs was high,
with frequent problems related to poor medication compliance, side effects,
and interactions with alcohol.
Overall, the investigators concluded that 40% of the clients showed im-
provement in both alcohol use and other life areas, with an additional 35%
showing improvement in one area or the other. Life areas most consistently re-
lated to the status of alcohol problems were personal hygiene, activities of daily
living, mental or cognitive health, and adequacy of diet. Also, physical health
was the most likely to covary with other life areas, and it declined with the
worsening of recent drinking status. Together the associations suggest a rela-
tionship between substance abuse and life areas related to maintaining clients
in the community. An informal follow-up found that about half of the subjects
maintained their gains after discharge. This thoughtfully conducted project ex-
ploring community outreach deserves careful reading and replication.
Family 7reatment
Despite early discussion of the importance offamily involvement (Dunlop,
Skorney, & Hamilton, 1982), a literature search yielded few studies specifically
evaluating family therapy for elderly substance abusers. Tabisz, Jacyk, Fuchs,
and Grymonpre (1993) have described the Elders Health Program, an interven-
tion program for chemically dependent seniors based in the emergency depart-
ment of an acute-care hospital. About a third of the patients (65 years or older)
were assessed as having active enablers in their family or social-professional
networks, and this was particularly true of women in the sample. Although
having an active enabler was not associated with outcome, patients with active
enablers required greater intensity of effort. If spouses or families refused to co-
operate, the coordinator stopped the intervention. Approximately half of the
identified cases showed improvement after an individualized level of interven-
tion. Although the enabling concept and Johnson Institute model have become
widely accepted, there has been surprisingly little systematic research in this
area (Liepman, Nirenberg, & Begin, 1989). There is a need for evaluating various
models of working with family members whose older member continues to
drink abusively, as well as the effectiveness of marital and family treatment for
seniors (see O'Farrell, 1993).
Self-Help Groups
Elderly patients are frequently referred to Alcoholics Anonymous and
other 12-step recovery groups, which have continued to grow in popularity
(Weisner, Greenfield, & Room, 1995). In 1990, older men (age 50 or over) with
dependency symptoms were more likely to go to Alcoholics Anonymous (AA)
or a private physician than other types of treatment. Accompanying this growth
in AA has been the development of specialized AA groups for elderly alco-
holics in some communities (Zimberg, 1995). Although no research was found
addressing the effectiveness of AA with elderly patients, current literature sug-
gests the importance of preparing patients to affiliate with AA and matching se-
lected patients to an appropriate group (McCrady & Miller, 1993).
Patient-'Jreatment Matching
The concept of patient-treatment matching has become more accepted se-
lecting appropriate treatment. A study by Rice, Longabaugh, Beattie, and Noel
(1993) is apparently the first one to report a significant age-by-treatment interac-
tion. A mixed age group (18 to 76 years) of 229 patients was randomly assigned
to cognitive-behavioral treatment, relationship enhancement, or an occupational
focus condition. The percentage of abstinent and heavy drinking days was ex-
amined 3 to 6 months after treatment assignment. Although there were no over-
all differences between treatment conditions or defined age groups, the older
patients (50 years or greater) did significantly better with cognitive-behavioral
treatment as opposed to the occupational focus. The authors suggest that this
may have been due to the reduced social influence and/or support associated
with the workplace in later years. It seems reasonable to conclude that the effec-
tiveness of treatment will vary with the perceived importance and influence of
issues addressed at a particular stage in the life cycle. This speaks again to the
importance of tailoring treatment programs to the psychosocial stressors in-
volved in aging. Patient-treatment matching, however, also refers to the need to
address important clinical and psychosocial issues found in selected subgroups
of elderly patients (i.e., the medically ill, dually diagnosed, and women).
Medically ill alcoholics are generally older. unable to work. retired. fre-
quently isolated or without family support, or combinations of these character-
istics, and more often present with multiple health concerns to medical
facilities. Frequently, they have refused referral to traditional treatment pro-
grams. Willenbring, Olson, Bielinski, and Lynch (1995) have described a dem-
onstration project in an outpatient primary care center to reach these patients
who have serious medical disorders, such as pancreatitis and liver disease. The
goal was to reduce alcohol-related morbidity through interventions that reduce
drinking and address psychosocial problems within the context of comprehen-
sive medical treatment and follow-up. As with other chronic diseases, partial
improvement and patient stabilization were seen as an acceptable goal in cases
where permanent abstinence (although more desirable) had not been attained.
Family and environmental interventions, asset management, and emergency
hospitalization were used with the assumption that such patients would re-
quire long-term treatment planning and outpatient care.
In an initial evaluation, 30 male veterans admitted into the program were
followed and their outcomes contrasted with a comparison group. Control pa-
tients met admission criteria but because of space limitations were treated else-
where in the medical center; they were all offered but declined conventional
alcoholism treatment. The mean age of the clinic patients was 61.5 years. For
patients in the program, clinic visits significantly increased and hospitalization
days declined. Moreover, there was less mortality (3%) relative to controls
(31 %) at a 13-month follow-up. In recognizing that patients continue to die
from medical complications of alcohol dependence, these investigators chal-
lenged the field to consider what alternative but caring treatments might be pro-
vided to this difficult subgroup of elderly patients.
Those older persons who have comorbid psychiatric or organic disorders
or both also pose a significant problem. The drinker whose cognitive or psychi-
atric problems appear to contribute to abusive drinking was one of three patient
types discussed in Graham and colleagues' (1995) typology of clients in the
Community Older Persons Alcohol project. Preexisting psychiatric disorder or
intermittent cognitive problems interfered with their understanding of the need
to control their drinking, often resulting in bizarre behavior and neglect of self-
care. Stabilizing psychiatric treatment, increasing compliance with medicines,
and dealing with the life sequelae of the person's drinking problem became the
focus. Speer, O'Sullivan, and Schonfeld (1991) have discussed policy and plan-
ning issues that must be addressed as such patients increasingly enter the pub-
lic mental health system.
Moos and colleagues (1993) found that such dually diagnosed older per-
sons required more inpatient care as well as outpatient treatment after dis-
charge and had higher 4-year readmission rates. Canter and Koretzky (1989)
also reported that organically impaired older alcoholics were less likely to ben-
efit from standard treatment and required a modified treatment approach. They
suggested greater emphasis on stress reduction, with an individualized didac-
tic approach to teaching about the physical and social impact of drinking. Also,
there is a need to take into account the possible information-processing deficits
of these patients, and evaluate the possible role of cognitive rehabilitation.
Finally, the distinct needs of older women with substance abuse problems
deserve mention. Knowledge about women with substance abuse problems has
proliferated with an increase in specialized treatment services (Galanter, 1995;

E. S. Gomberg & Nirenberg, 1993; Szwabo, 1993). As discussed above, elderly
women in treatment report more drinking problems among family members,
have a later age of onset and shorter duration of alcohol abuse, report more de-
pressive feelings, and are much more likely to be using prescribed tranquiliz-
ers in addition to alcohol (E. S. L. Gomberg, 1995b). Although it is not clear
whether these patients are best provided services in treatment centers for
women or specialized programs for the elderly, all treatment should be sensi-
tive to gender issues.
Prevention
The need for research on health promotion and alcohol problem prevention
among elderly persons is now just emerging as a national health care priority
(Abdellah, 1988; Gilford, 1988; Noel & McCrady, 1984; Office of Technology As-
sessment, 1985). As a result, there have been few alcohol prevention studies tar-
geted specifically toward older persons (Institute of Medicine, 1989; National
Institute on Alcohol Abuse and Alcoholism, 1990). Existing studies focus on
clinical samples of elderly alcoholics or problem drinkers to assess the need for
or the differential impact of tertiary care, or both, or involve efforts to increase
early detection (Beresford, Blow, Brower, Adams, & Hall, 1988; F. Blow, 1990;
Curtis, Geller, Stokes, Levine, & Moore, 1989; Janik & Dunham, 1983; Kofoed et
aI., 1987). Evaluative studies of health promotion and disease prevention pro-
grams with older persons drawn from other fields, however, generally provide
evidence that health promotion education programs are usually well received by
the elderly, and can lead to substantial improvements in health knowledge,
skills performance, increased efforts to improve life-style, and improvements in
the quality of life (Hersey, Glass, & Crocker, 1984; Nelson et aI., 1984).
As a group, older persons are very concerned with their health. Those aged
65 or over demonstrate greater compliance with many (but not all) recom-
mended health behaviors (German, 1978; National Center for Health Statistics,
1986) and typically perceive those behaviors to be more efficacious than do per-
sons under age 65 (Bausell, 1986; Nelson et aI., 1984). Paradoxically, although
older adults may be among the most health conscious, they also appear to be
most in need of health information. Data from the 1985 Disease Prevention
Health Promotion supplement to the National Health Interview survey indicate
that persons aged 65 or over have the highest rates of "do not know/no opinion"
responses to information items regarding the health effects of smoking, alcohol
use, exercise, dietary, and dental behavior (National Center for Health Statistics,
1986). For example, at least 33% to 50% of all persons aged 65 or over re-
sponded "do not know" or "no opinion" to questions assessing knowledge of
the association between alcohol consumption and the risk of throat, bladder
or mouth cancer, arthritis, and blood clots. Such lack of information can be
addressed through prevention initiatives focused on health promotion and
health education.
Hospitals are an important community site for health promotion for older
persons. Since 1979, the House of Delegates ofthe American Hospital Associa-
tion has encouraged hospitals to identify target areas and population groups for
hospital-based health promotion and disease prevention programs (American
Hospital Association. 1979), and older persons are among the most frequent tar-
get populations of these efforts. Studies suggest that more than 40% of hospitals
have a health promotion program for older patients and their families (Longe,
1986). In addition to the enhanced availability oftarget populations. the hospi-
tal setting provides many unique opportunities for the identification, interven-
tion, and prevention of alcohol problems (Babor, Ritson, & Hodgson, 1986;
Institute of Medicine, 1990). Researchers consistently point to the general hos-
pital as one of the best sites in which to identify and conduct alcohol problem
prevention activities with at-risk elderly drinkers (Babor et a1., 1986; F. Blow,
1990; Brody, 1982). The hospital affords an opportunity to intervene with a cap-
tive population, who may be especially receptive to health promotion and prob-
lem prevention initiatives (Nutting, 1986). Techniques for screening and
intervention have shown that the implementation of such programs is feasible
and well accepted by general hospital patients (Lewis & Gordon, 1983). Further,
the infrastructure of many hospitals already supports staff members who regu-
larly conduct preventive interventions.
SUMMARY
The number of older persons in our communities will continue to grow over
the next three decades. While available statistics as to prevalence of substance
abuse among older individuals are only estimates, it is clear that older persons
are not immune to this problem. In fact, due to biological and psychosocial char-
acteristics, many older adults may be prone to developing substance abuse. Al-
though it has been stated for years that elderly substance abusers (and for that
matter many other special groups) require at least some degree of specialized
care, to date the outcome data are lacking. However. interest in the elderly is evi-
dent and specialized programs may yet increase in number. There clearly is a
need to develop a variety of intervention and treatment services for elderly pa-
tients with substance use or abuse problems, in keeping with their unique
biopsychosocial factors and specific circumstances. Descriptive studies on this
population should now give way to those testing specific treatments. The inter-
ventions and settings that work best for particular segments of the elderly popu-
lation should be explored. The general finding that older patients in treatment
do at least as well as younger patients (Atkinson, 1995), given the early stage of
development of such programming, suggests that a great many more older per-
sons with substance abuse difficulties can be effectively helped.
REFERENCES
Abdellah. F. G. (1988). Surgeon General's workshop on health promotion and aging: Proceedings.
Department of Health and Human Services, U.S. Public Health Service. March 20-23.
Abrams, R. C., & Alexopoulous, G. S. (1988). Substance abuse in the elderly: Over-the-counter and
illegal drugs. Hospital and Community Psychiatry, 39, 822-829.
Adams, W. L., Garry, P. J., Rhyne, R., Hunt, W. C., & Goodwin, J. S. (1990). Alcohol intake in the
healthy elderly: Changes with age in a cross-sectional and longitudinal study. Journal of the
American Geriatric Society, 38, 211-216.
Alexander, F., & Duff, R W. (1988). Social interaction and alcohol use in retirement communities.
American Hospital Association. (1979). The hospital's responsibility for health promotion. Policy
statement from the American Hospital Association House of Delegates, Chicago.
American Medical Association. (1995). Alcoholism in the elderly: Diagnosis, treatment, prevention:
Guidelines for primary care physicians. Chicago: Author.
(4th ed.). Washington. DC: Author.
Annual Medical Examiner Data 1993. (1995). Data from the Drug Abuse Warning Network (DAWN),
Series 1, No. 13B (DHHS Publication No. (SMA) 95-3019). Rockville. MD: U.S. Department of
Health and Human Services.
Atkinson, R M. (1984). Alcohol and drug abuse in old age. Washington, DC: American Psychiatric
Press.
Atkinson, R M. (1990). Aging and alcohol use disorders: Diagnostic issues in the elderly. Interna-
tional Psychogeriatrics, 2, 55-72.
Atkinson, R M. (1995). Treatment programs for aging alcoholics. In T. P. Beresford & E. Gomberg
(Eds.), Alcohol and aging (pp. 186-210). New York: Oxford University Press.
Atkinson. R. M., 'furner, J. A., Kofoed. 1. L., & Tolson, R L. (1985). Early versus late onset alco-
holism in older persons: Preliminary findings. Alcoholism: Clinical and Experimental Re-
search, 9, 513-515.
Atkinson, R M., Tolson. R L.. & Turner, J. A. (1990). Late versus early onset problem drinking in
older men. Alcoholism: Clinical and Experimental Research, 14, 574-579.
Atkinson, R M.. Tolson, R L., & 'furner, J. A. (1993). Factors affecting outpatient treatment compli-
ance of older male problem drinkers. Journal of Studies on Alcohol, 54, 102-106.
Azrin, N. H .. Sisson. R W.• Meyers. R, & Godley. M. (1982). Alcoholism treatment by disulfiram
and community reinforcement therapy. Journal of Behavior Therapy and Experimental Psy-
chiatry, 13, 105-112.
Babor, T. F.. Ritson. E. B., & Hodgson, R J. (1986). Alcohol-related problems in the primary health
care setting: A review of early intervention strategies. British Journal of Addiction, 81, 23-46.
Babor, T. F., Stevens, R S., & Marlatt, G. A. (1987). Verbal report methods in clinical research on al-
coholism: Response bias and its minimization. Journal of Studies on Alcohol, 48, 410-424.
Bailey, M. P., Haberman, P. W.. & Alksne. H. (1965). The epidemiology of alcoholism in an urban
residential area. Quarterly Journal of Studies on Alcohol, 26, 19-40.
Bausell, R B. (1986). Health-seeking behavior among the elderly. Gerontologist, 26, 556.
Beck, A. T., Wright, F. D., Newman, C. F., & Liese, B. S. (1993). Cognitive therapy of substance abuse.
New York: Guilford.
Beresford, T. P., & Gomberg, E. S. L. (1995). Alcohol and aging. New York: Oxford University Press.
Beresford, T. P., Blow, F. C., Brower, K. J., Adams, K. M., & Hall, R C. (1988). Psychosomatics, 29,
61-72.
Berman, B. A., & Gritz, E. R (1993). Women and smoking: Toward the year 2000. In E. S. Lisansky-
Gomberg & T. D. Nirenberg (Eds.), Women and substance abuse (p.p. 258-285), Norwood, NJ:
Ablex. .
Blow, F. (1990, April 6). Screening for elderly alcohol problems. Paper presented at Aging in the
1990s Alcohol and Other Drug Abuse Conference, Western Michigan University, Novi, MI.
Blow, F. C., Brower, K. J., Schulenberg, J. E., Demo-Dananberg, L. M., Young, K. J., & Beresford, T. P.
(1992). The Michigan alcoholism screening test. Geriatric version (MAST-G): A new elderly-
specific screening instrument [Abstract]. Alcoholism Clinical IT Experimental Research, 16
(2), 105, 372.
Brennan, P. 1., & Moos, R H. (1991). Functioning, life context, and help-seeking among late-onset
problem drinkers: Comparisons with non problem and early-onset problem drinkers. British
Journal of Addiction, 86, 1139-1150.
Brennan, P. 1., & Moos, R. H. (1995). Life context, coping responses, and adaptive outcomes: A
stress and coping perspective on late-life problem drinking. In T. P. Beresford & E. Gomberg
(Eds.), Alcohol and aging (pp. 230-248). New York: Oxford University Press.
Brennan, P. L., Moos, R H., & Mertens, J. R (1994). Personal and environmental risk factors as pre-
dictors of alcohol use, depression, and treatment seeking: A longitudinal analysis of late-life
problem drinkers. Journal of Substance Abuse, 6, 191-208.
Brody, J. A. (1982). Aging and alcohol abuse. Journal of the American Geriatrics Society. 30. 123-126.
Brower, K. J., Mudd, S., Blow, F. C., Young, J. P., & Hall, E. M. (1994). Severity and treatment of al-
cohol withdrawal in elderly versus younger patients. Alcoholism: Clinical and Experimental
Research, 18, 196-201.
Canter, W. A., & Koretzky, M. B. (1989). Treatment of geriatric alcoholics. Clinical Gerontologist, 9,
67-70.
Carp, F. M. (1989). Maximizing data quality in community studies of older people. In M. P. Lawton
& A. R. Regula (Eds.)., Special research methods for gerontology. Amityville, NY: Baywood.
Carstensen, L. L., Rychtarik, R. G., & Prue, D. M. (1985). Behavioral treatment ofthe geriatric alco-
hol abuser: A long term follow-up study. Addictive Behaviors, 10, 307-311.
Curtis, J. R., Geller, G., Stokes, E. J., Levine, D. M., & Moore, R. D. (1989). Characteristics, diagnosis,
and treatment of alcoholism in elderly patients. Journal of the American Geriatric Society, 37,
310-316.
DeHart, S. S., & Hoffman, N. G. (1995). Screening and diagnosis of "alcohol abuse and dependence"
in older adults. The International Journal of the Addictions, 3D, 1717-1747.
DesJarlais, D. C., Joseph, H., & Courtwright, D. (1985). Old age and addiction: A study of elderly pa-
tients in methadone maintenance treatment. In E. Gottheil, K. A. Druley, T. E. Skoloda, &
H. M. Waxman (Eds.)., The combined problems of alcoholism, drug addiction, and aging (pp.
201-209). Springfield, IL: Thomas.
Douglas, R. L. (1984). Aging and alcohol problems: Opportunities for socioepidemiological re-
search. In M. Galanter (Ed.), Recent developments in alcoholism (Vol. 2. pp. 251-266). New
York: Plenum.
Dunham, R. G. (1981). Aging and changing patterns of alcohol use. Journal of Psychoactive Drugs,
13, 143-151.
Dunlop, J., Skorney, B., & Hamilton, J. (1982). Group treatment for elderly alcoholics and their fam-
ilies. Social Work in Groups, 5, 87-92.
Dupree, L. w., Broskowski, H., & Schonfeld, L. (1984). The gerontology alcohol project: A behav-
ioral treatment program for elderly alcohol abusers. Gerontologist. 24. 510-516.
Eaton, W. W., Kramer, M., & Anthony, J. C. (1989). The incidence of specific DISIDSM-m mental dis-
orders: Data from the N.I.M.H. Epidemiologic Catchment Area Program. Acta Psychiatrica
Scandinavia, 79, 163-178.
Epstein. L. J., Mills, C.• & Simon. A. (1970). Antisocial behavior of the elderly. Comprehensive Psy-
chiatry, 11, 36-42.
Ewing. J. A. (1984). Detecting alcoholism: the CAGE questionnaire. Journal of the American Med-
ical Association. 252,1905-1907.
Fillmore. K. M. (1987). Prevalence, incidence. and chronicity of drinking patterns and problems
among men as a function of age: A longitudinal and cohort analysis. British Journal of Addic-
tion, 82, 77-83.
Fillmore, K. M., Hartka, E., Johnstone. B. M., Leino, E. V., Motoyoshi, M.. & Temple, M. T. (1991). A
meta-analysis of life course variation in drinking. British Journal of Addiction, 86, 1221-1268.
Finlayson, R. E.• Hurt, R. D., Davis, N. J.. & Morse. R. M. (1988). Alcoholism in elderly persons: A
study of the psychiatric and psychosocial features of 216 inpatients. Maya Clinic Proceedings,
63, 761-768.
Finney, J. W., & Moos, R. H. (1995). Entering treatment for alcohol abuse: A stress and coping per-
spective. Addiction, 90, 1223-1240.
Finney, J. W., Moos, R. H., & Brennan, P. L. (1991). The drinking problems index: A measure
to assess alcohol-related problems among older adults. Journal of Substance Abuse, 3,
395-404.
Fogel, B. S., Furino, A., & Gottlieb, G. L. (1990). Mental health policy for older Americans: Protect-
ing minds at risk. Washington, DC: American Psychiatric Press.
Galanter, M. (1995). Recent developments in alcoholism: Alcoholism in women (Vol. 12). New York:
Plenum.
Gambert, S. R. (1992). Substance abuse in the elderly. In J. H. Lowinson, P. Ruiz. & R. B. Millman
(Eds.), Substance abuse: A comprehensive textbook (2nd ed., pp. 843-851). Baltimore:
Williams & Wilkins.
German, P. (1978). The elderly: A target group highly accessible to health education. International
Journal of Health Education, 21, 267-272.
Gilford. D. M. (1988). The aging population in the twenty-first century: Statistics for health policy.
Committee on National Statistics. Commission on Behavioral and Social Sciences and Edu-
cation. National Research Council. Washington. DC: National Academy Press.
Glatz. M. D. (1995). Cognitive therapy with elderly alcoholics. In T. P. Beresford & E. Gomberg
(Eds.). Alcohol and aging (pp. 211-229). New York: Oxford University Press.
Glynn. R. 1.. Bouchard. G. R.. LoCastro. J. S .. & Laird. N. M. (1985). Aging and generational effects
on drinking behaviors in men: Results from the Normative Aging Study. American Journal of
Public Health. 75.1413-1419.
Gomberg. E. S .. & Nirenberg. T. D. (Eds.). (1993). Women and substance abuse. Norwood. NJ: Ablex.
Gomberg. E. S. L. (1982). Alcohol use and alcohol problems among the elderly. Alcohol and Health
Monograph 4 (NIAAA DHHS Publication No. (ADM) 82-1193). Special population issues (pp.
263-290). Rockville. MD: U.S. Department of Health and Human Services.
Gomberg. E. S. 1. (1987). Drug and alcohol problems of elderly persons. In T. D. Nirenberg & S. A.
Maisto (Eds.). Developments in the assessment and treatment of addictive behaviors (pp.
319-337). Norwood. NJ: Ablex.
Gomberg. E. S. 1. (1990). Drugs. alcohol. and aging. In 1. T. Kozlowski. H. M. Annis. H. D. Cap-
pell. F. B. Glaser. E. M. Sellers. M. S. Goodstodt. Y. Israel. H. Kalatant, & E. R. Vingilis
(Eds.). Research advances in alcohol and drug problems (Vol. 10. pp. 171-213). New York:
Plenum.
Gomberg. E. S. 1. (1992). Medication problems and drug abuse. In F. J. Turner (Ed.). Mental health
and the elderly (pp. 355-374). New York: Free Press.
Gomberg. E. S. L. (1995a). Older alcoholics: Entry into treatment. In T. P. Beresford & E. Gomberg
(Eds.). Alcohol and aging (pp. 169-185). New York: Oxford University Press.
Gomberg. E. S. 1. (1995b). Older women and alcohol: Use and abuse. In M. Galanter (Ed.). Recent
developments in alcoholism (Vol. 12. pp. 61-79). New York: Plenum.
Gomberg. E. S. 1.. & Nelson. B. W. (1995). Black and white older men: Alcohol use and abuse. In
T. P. Beresford & E. S. 1. Gomberg (Eds.). Alcohol and aging (pp. 307-323). New York: Oxford
University Press.
Gomberg. E. S. 1.. Hsieh. G.. & Adams. K. M. (1990). Patterns of drug use in a general medical care
clinic for veterans. A pilot study. In B. B. Wilford (Ed.). Balancing the response to prescription
drug use (pp. 119-132). Chicago: American Medical Association.
Gordon. T.. & Kannel. W. B. (1983). Drinking and its relation to smoking. blood pressure. blood
lipids. and uric acid. Archives of Internal Medicine. 146. 262-265.
Gorelick. D. A. (1993). Pharmacological treatment. In M. Galanter (Ed.). Recent developments in al-
coholism (Vol. 11. pp. 413-427). New York: Plenum.
Graham. K. (1984). Identifying and measuring alcohol abuse among the elderly: Serious problems
with existing instrumentation. Journal of Studies on Alcohol. 47. 253-262.
Graham. K.. Saunders. S. J.. Flower. M. c.. Timney. C. B.. White-Campbell. M .. & Pietropaolo. A. Z.
(1995). Addictions treatment for older adults: Evaluation of an innovative cJient-centered ap-
proach. New York: Haworth.
Helzer. J. E.. Burnham. A .. & McEvoy. 1. T. (1991). Alcohol use and dependence. In 1. N. Robins &
D. A. Regier (Eds.). Psychiatric disorders in America: The epidemiologic catchment area study
(pp. 81-115). New York: Macmillan.
Hersey. J. C.. Glass. 1. 1.. & Crocker. P. (1984). Aging and health promotion behavior: Marketing
research for public education. Final report prepared under contract number DDS/OASH
282-83-105. Rockville. MD: U.S. Department of Health and Human Services.
Huffine. C.• Folkman. S .• & Lazarus. R. S. (1989). Psychoactive drugs. alcohol. and stress and cop-
ing processes in older adults. American Journal of Drug and Alcohol Abuse. 15. 101.
Hurt. R. D.• Finlayson. R. E.. & Morse. R. M. (1988). Alcoholism and elderly persons: Medical as-
pects and prognosis of 216 patients. Mayo Clinic Proceedings. 63. 753-760.
Institute of Medicine. (1989). Prevention and treatment of alcohol problems: Research opportuni-
ties. Report of a study by a Committee of the 10M. Division of Mental Health and Behavioral
Medicine. Washington. DC: National Academy Press.
Institute of Medicine. (1990). Broadening the base of treatment for alcohol problems. Washington.
DC: National Academy Press.
Janik. S. W.• & Dunham. R. G. (1983). A nationwide examination of the need for specific alcoholism
treatment programs for the elderly. Journal of Studies on Alcohol. 44. 307-317.
Jennison, K. M. (1992). The impact of stressful life events and social support on drinking among
older adults: A general population survey. International Journal of Aging and Human Devel-
opment, 35, 99-123.
Johnson, L. K. (1989). How to diagnose and treat chemical dependency in the elderly. Journal of
Gerontological Nursing, 15, 22-26.
Jones, T. V., Lindsey, B. A., Yount, P., Soltys, R., & Farani-Enayat, B. (1993). Alcoholism screening
questionnaires: Are they valid in elderly medical outpatients? Journal of General Internal
Medicine, 8, 674-678.
King, C. J., Van Hasselt, V. B., Segal, D. L., & Hersen, M. (1994). Diagnosis and assessment of sub-
stance abuse in older adults: Current strategies and issues. Addictive Behaviors, 19,41-55.
Kleber, H. D. (1990). The nosology of abuse and dependence. Journal of Psychiatric Research, 24,
(Supp!. 2), 57-64.
Kofoed,1. L., Tolson, R. L., Atkinson, R. M., Toth, R. L., & Thrner, J. A. (1987). Treatment compli-
ance of older alcoholics: An elder-specific approach is superior to "mainstreaming." Journal
of Studies on Alcohol, 48, 47-51.
Kopelman, M. D. (1995). The Korsakoff syndrome. British Journal of Psychiatry, 166. 154-173.
Krashner, T. M., Rodell. D. E., Ogden. S. R.. Guggenheim. F. G.• & Karson. C. N. (1992). Outcomes
and costs oftwo VA inpatient treatment programs for older alcoholic patients. Hospital and
Community Psychiatry, 43, 985-989.
Krause, N. (1995). Stress, alcohol use. and depressive symptoms in later life. Gerontologist, 35,
296-307.
Laforge. R. G., Nirenberg. T. D.• Lewis, D.C.• & Murphy. J. B. (1993). Problem drinking. gender. and stress-
fullife events among hospitalized elderly drinkers. Behavior, Health, and Aging, 3, 129-138.
Lawson. A. W. (1989). Substance abuse problems ofthe elderly: Considerations for treatment and
prevention. In G. W. Lawson & A. W. Lawson (Eds.), Alcoholism and substance abuse in spe-
cial populations (pp. 95-113). Gaithersburg. MD: Aspen.
Lewis. D.C. (1995, October 2-5). Training about alcohol and substance abuse for all primary care
physicians. Proceedings of conference. Phoenix, AZ. New York: Josiah Macy, Jr. Foundation.
Lewis, D.C., & Gordon. A. J. (1983). Alcoholism and the general hospital: The Roger Williams Inter-
vention Program. Bulletin-New York Academy of Medicine. 59. 181-197.
Liepman. M. R.. Nirenberg, T. D., & Begin. A.M. (1989). Evaluation of a program designed to help
family and significant others to motivate resistant alcoholics into recovery. American Journal
of Drug and Alcohol Abuse, 15, 209-221.
Longe, M. E. (1986). Elderly hospitalization programs. In K. Dychtwald (Ed.). Wellness and health
promotion for the elderly. Rockville. MD: Aspen Systems.
McCrady, B. S., & Miller, W. R. (1993). Research on alcoholics anonymous. Piscataway. NT: Rutgers
Center of Alcohol Studies.
Michigan Department of Public Health. (1994). Substance abuse services for older adults (OA
089/10M9-84/NONOG). Lansing. MI: Author.
Miller. N. S., Belkin, B. M .• & Gold. M. S. (1991). Alcohol and drug dependence among the elderly:
Epidemiology, diagnosis. and treatment. Comprehensive Psychiatry, 32, 153-165.
Molgard. C.A.. Nakamura, C. N .• Stanford. E. P.• Peddecord, K. M .• & Morton. D. J. (1990). Prevalence
of alcohol consumption among older persons. Journal of Community Health, 15, 239-251.
Moos, R. H., Mertens, J. R.. & Brennan, P. 1. (1993). Patterns of diagnosis and treatment among
late-middle-aged and older substance abuse patients. Journal of Studies on Alcohol. 54,
479-487.
Moos, R. H., Mertens, J. R., & Brennan, P. L. (1994). Rates and predictors of four-year readmission
among late-middle-aged and older substance abuse patients. Journal of Studies on Alcohol,
55, 561-570.
National Center for Health Statistics. (1986). Health promotion data for the 1990 objective: Esti-
mates from the National Health Interview Survey of Health Promotion and Disease Preven-
tion: United States, 1985, Advance Data from Vital and Health Statistics, No. 126 (DHHS
Publication No. (PHS) 86-1250). Hyattsville, MD: U.S. Public Health Service.
National Institute on Alcohol Abuse and Alcoholism. (1990). Alcohol and health: Seventh special
report to the U.S. Congress. Rockville, MD: Public Health Service. U.S. Department of Health
and Human Services.
Nelson, E., McHugo, G., Schnurr, P., Devito, C., Roberts, E., Simmons, J., & Zubkoff, W. (1984). Med-
ical self-care education for elders: A controlled trial to evaluate impact. American Journal of
Public Health, 74,1357-1363.
Nirenberg, T. D., & Maisto, S. A. (1990). The relationship between assessment and alcohol treat-
ment. The International Journal of the Addictions, 25, 1275-1285.
NoeL N. E., & McCrady, B. S. (1984). Target populations for alcohol abuse prevention. In P. M. Miller
& T. D. Nirenberg (Eds.), Prevention of alcohol abuse (pp. 55-96). New York: Plenum.
Nutting, P. A. (1986). Health promotion in primary care: Problems and potential. Preventive Medi-
cine, 15,537-548.
O'Farrell, T. J. (1993). Treating alcohol problems: Marital and family interventions. New York: Guilford.
Office of Technology Assessment. (1985). Technology and aging in America (OTA-B-A-264). Wash-
ington, DC: U.S. Government Printing Office.
Paganini-Hill, A., Ross, R K, & Henderson, B. E. (1986). Prevalence of chronic disease and health
practices in a retirement community. Journal of Chronic Diseases, 39, 699-707.
Prentice, R (1979). Patterns of psychotherapeutic drugs use among the elderly. In The aging process
and psychoactive drug use (pp. 17-41). National Institute of Drug Abuse. Washington, DC:
U.S. Government Printing Office.
Rice, c., Longabaugh, R, Beattie, M., & NoeL N. (1993). Age group differences in response to treat-
ment for problematic alcohol use. Addiction, 88, 1369-1375.
Rosin, A. J., & Glatt, M. M. (1971). Alcohol excess in the elderly. Quarterly Journal of Studies on Al-
cohol, 32, 53-59.
Rubington, E. (1982). The chronic drunkenness offender on Skid Row. In E. S. 1. Gomberg, H. R
White, & J. A. Carpenter (Eds.), Alcohol, science and society revisited (pp. 322-336). Ann Ar-
bor: University of Michigan Press.
Schonfeld, 1., & Dupree, 1. W. (1991). Antecedents of drinking for early- and late-onset elderly al-
cohol abusers. Journal of Studies on Alcohol, 52, 587- 592.
Schutte, K. K, Brennan, P. 1., & Moos, R H. (1994). Remission of late-life drinking problems: A four
year follow-up. Alcoholism: Clinical and Experimental Research, 18,835-844.
Sellers, E. M., Frecker, R C., & Romach, M. L. (1982). Drug metabolism in the elderly: Confounding
of age, smoking and ethanol effects. Substudy 1219. Toronto. Ontario, Canada: Addiction Re-
search Foundation.
Selzer. M. 1. (1971). The Michigan Alcoholism Test: The quest for a new diagnostic instrument.
American Journal of Psychiatry, 127, 1653-1658.
Sobell, L. C., Sobel!, M. B., & Nirenberg, T. D. (1988). Behavioral assessment and treatment planning
with alcohol and drug abusers: A review with an emphasis on clinical application. Clinical
Psychology Review, 8, 19-54.
Solomon, K, Manepalli, J., Ireland, G. A., & Mahon. G. M. (1993). Alcoholism and prescription drug
abuse in the elderly: St. Louis University grand rounds. Journal of the American Geriatric So-
ciety, 41, 57-69.
Speer, D. C., O'Sullivan, M., & Schonfeld. L. (1991). Dual diagnosis among older adults: A new ar-
ray of policy and planning problems. Journal of Mental Health Administration, 18, 43-50.
Szwabo, P. A. (1993). Substance abuse in older women. Clinics in Geriatric Medicine, 9, 197-208.
Tabisz, E. M., Jacyk, w. R, Fuchs, D., & Grymonpre, R (1993). Chemical dependency in the elderly:
The enabling factor. Canadian Journal on Aging, 12, 78-88.
Tucker, J. A., Gavornik, M. G., Vuchinich. R E., Rudd, E. J., & Harris, C. V. (1989). Predicting the
drinking behavior of older adults from questionnaire measures of alcohol consumption. Ad-
dictive Behaviors, 14,655-658.
Victor, M., Adams, R A., & Collins, G. H. (1989). The Wernicke-Korsakoff syndrome and related
disorders due to alcoholism and malnutrition, Philadelphia: Davis.
Wartenberg, A. A., & Nirenberg, T. D. (1995). Alcohol and other drug abuse in older patients. In W.
Reichel (Ed.), Care of the elderly: Clinical aspects of aging (4th ed., pp. 133-141). Baltimore:
Williams & Wilkins.
Weisner, C., Greenfield, T., & Room, R (1995). Trends in the treatment of alcohol problems in the
U.S. general population, 1979-1990. American Journal of Public Health, 85, 55-60.
Welte, J. W., & Mirand, A. 1. (1993). Drinking, problem drinking, and life stressors in the elderly
general population. Journal of Studies on Alcohol, 56, 67-73.
172 Ted D. Nirenberg et oJ.
Werch. C. (1989). Quantity-frequency and diary measures of alcohol consumption for elderly
drinkers. International Journal of the Addictions. 24, 859-865.
Willenbring, M. 1.. Christensen. K. J., Spring, W. D., & Rasmussen, R. (1987). Alcoholism screening
in the elderly. Journal of the American Geriatric Society, 35, 864-869.
Willenbring, M. 1., Olson, D., Bielinski, J., & Lynch, J. (1995). Treatment of medically ill alcoholics
in the primary-care setting. In T. P. Beresford & E. Gomberg (Eds.), Alcohol and aging (pp.
249-262). New York: Oxford University Press.
Zimberg, S. (1974). Two types of problem drinkers. Geriatrics, 29, 135-139.
Zimberg, S. (1995). The elderly. In A. M. Washton (Ed.). Psychotherapy and substance abuse (pp.
413-427). New York: Guilford.
CHAPTER 9
Schizophrenia
STEPHEN J. BARTELS, KIM T. MUESER,
AND KEITH M. MILES
INTRODUCTION
Overview
Schizophrenia is a severe and frequently debilitating illness that affects one

percent of the population (Gurland & Cross, 1982). Not surprisingly, there is a
substantial literature of the phenomenology, course, biology, and treatment of
schizophrenia in young adults. However, there is a remarkable lack of data on
this disorder in late life. In this chapter we provide an overview of the clinical
features of schizophrenia and aging. First, we will discuss changing views on
the onset and outcome of schizophrenia, including features of early- and late-
onset schizophrenia in the elderly. Next, we will discuss factors that appear to
be important in the long-term outcome of schizophrenia, including the role of
age cohorts, family resources, antipsychotic medication, and medical com or-
bidity. Finally, we will outline the elements of a strategy for the treatment of
schizophrenia in the elderly based on the application of a comprehensive
biopsychosocial model.
A Changing View of Schizophrenia
Early views of schizophrenia maintained that the disorder always began in

young adulthood and inevitably resulted in a progressive deterioration of func-
tion, thinking, and cognition. The term "dementia praecox" was introduced by
Kraepelin (1919/1971) to describe this characteristic course and outcome ofthe
STEPHEN J. BARTELS, KIM T. MUESER, AND KEITH M. MILES • Department of Psychiatry and Community
and Family Medicine. New Hampshire-Dartmouth Psychiatric Research Center. Dartmouth Med-
ical School. Concord. New Hampshire 03301.
173
174 Stephen J. Bartels et a1.
disorder. However, his early view of schizophrenia has been replaced by a more
optimistic and dynamic understanding of the disorder as the result of longitu-
dinal research on schizophrenia and recent studies on schizophrenia in late
life. Among the five studies of the long-term course of schizophrenia, the pre-
ponderance of the data suggests a remarkably favorable outcome over time,
with 46% to 68% substantially improved, including 18% to 22% experiencing
global recovery (Bleuler, 1974; Ciompi, 1980; Harding, Brooks, Ashigawa,
Strauss, & Breier, 1987a,b; Huber, Cross, Schuttler, & Linz, 1989; M. Tsuang &
Winokur, 1975). However, these studies fail to provide definitive data on the
outcome of schizophrenia in old age, and they do not all agree that improve-
ment occurs in all areas of functioning. For example, these studies have been
widely interpreted to suggest a benign long-term outcome for most older indi-
viduals with schizophrenia, yet in four of the five studies the majority of pa-
tients were less than 65 years of age at follow-up. Furthermore, consensus is
lacking on functional outcomes. For example, two of the five studies reported
that social functioning was fair to poor for two thirds of the patients at follow-
up (Ciompi 1980; M. Tsuang & Winokur, 1975). In general, however, these data
indicate a historical shift to a more optimistic view of the long-term outcome
of schizophrenia.
Views of treatment and systems for care for those with schizophrenia have
also changed. Traditional institutional care models have been replaced by a dif-
ferent model of care emphasizing community treatment, with greater promise
of normalized life functioning. Advances in mental health treatment and gen-
eral medical care have resulted in more individuals with schizophrenia surviv-
ing into old age than before (Moak, 1996). However, this shift in the locus of
treatment from institutional settings to the community has largely focused on
younger adults and has included innovations in vocational rehabilitation, treat-
ment of comorbid substance abuse, and the development of assertive case man-
agement teams. Despite advances in treatment of these disorders, service
models specifically designed for the older adult with severe and persistent
mental illness are still lacking (Light & Lebowitz, 1991). In this context, the cur-
rent growth in the number of elderly persons with schizophrenia will present a
major challenge to the health care system and society.
AGE AND THE ONSET OF SCHIZOPHRENIA
While onset of schizophrenia usually occurs in late adolescence or early

adulthood, recent findings show that the disorder can begin in middle age and,
less commonly, in old age. In a review of eight studies of late-onset schizophre-
nia, Harris and Jeste (1988) estimated that almost one quarter (23%) of patients
with schizophrenia have onset of their disorder after age 40, including 13% be-
tween ages 40 and 50, 7% between the ages 50 and 60, and 3% after the age of
60. In a separate report of a 20-year study of first diagnosis of psychiatric disor-
ders in the community in Camberwell catchment area of London, England, D.
Castle, Wessely, Der, and Murray (1991) reported that 28% of patients with
schizophrenia had an onset of the illness after age 44, and 12% after age 64.
Overall, the annual incidence rate for late-onset schizophrenia was 12.6 per
Schizophrenia 175
100,000, approximately half of that for those aged 16 to 25. Differences in age of
onset appear to relate to clinical features of schizophrenia, resulting in descrip-
tive subtypes of schizophrenia in the elderly.
Based on age of onset, two broad groups of older adults with schizophrenia
have been described with overlapping but different symptom profiles. One
group of older individuals developed schizophrenia as young adults: they have
early-onset schizophrenia (EOS). This group first became ill at an early age and
continues to have symptoms of schizophrenia in old age. A second group, with
late-onset schizophrenia (LOS). is composed of elderly adults who developed
their illness in middle or old age. These individuals were largely free of symp-
toms of major mental illness during their early adult years, yet developed psy-
chotic illness as they became older. In the following sections we first describe
older individuals with lifelong schizophrenia (EOS), and then those with late-
onset schizophrenia (LOS), illustrating the importance of the factors discussed
above in assessment and treatment.
Early-Onset Schizophrenia
Individuals with early-onset schizophrenia (EOS) typically experience dis-

ordered thinking and unusual behavior that have a negative effect on their per-
sonal, social, and vocational lives. Although schizophrenia occurs with wide
variation in the type and severity of symptoms in different individuals, com-
mon problems include difficulties in initiating and maintaining relationships,
impaired role function (e.g., problems in education. employment), and deficits
in basic self-care or community living skills (e.g., grooming, hygiene. manag-
ing finances). These problems generally develop following persistent symptoms
of psychosis, although early signs of schizophrenia can also include progressive
difficulties in social functioning. For example, the first onset of psychosis may
be preceded by difficulties in social adjustment and interpersonal relationships
with gradual signs of social withdrawal (Zigler & Glick, 1986). These early signs
of schizophrenia generally develop over a period of months and can also in-
clude prodromal symptoms, such as depression. disordered thinking. and a de-
cline in interest and spontaneity. Problems may appear in the workplace.
school, or home setting, reflecting early difficulties in thinking and perceptions.
Relationships with family members or friends may be affected by the patient's
unusual behavior or by hostile or paranoid verbalizations.
The final onset of psychosis is often marked by dramatic and severe symp-
toms and functional difficulties. Three major symptom clusters are commonly
described, including positive, negative, and affective symptoms.
Positive symptoms consist of the primary active symptoms of psychosis,
most commonly delusions and hallucinations, but also including severely dis-
ordered thought processes such as illogical or unrelated thoughts or associa-
tions. Behavioral problems, such as bizarre behaviors, repetitive or ritualistic
behaviors, and posturing, are also examples of positive symptoms. Positive
symptoms are among the most common and noticeable signs of acute relapse
and may indicate a need for more intensive treatment, including hospitaliza-
tion. However, in the early stage of psychotic relapse, these symptoms can
sometimes be identified and brought to the attention of care providers. Appro-

priate adjustments in medication dosage and crisis stabilization treatment may
avert full symptomatic relapse and hospitalization. Increasingly, clinicians are
using educational sessions with patients and their families to help them recog-
nize early signs of relapse. Then changes can be implemented in treatment to
avoid an acute psychotic episode (Herz, 1985) This clinical use of early symp-
toms to suggest treatment changes represents the more recent view of schizo-
phrenia as subject to treatment and management by clinician, patient, and
patient's family.
The term negative symptoms applies to symptoms characterized by a lack
of active or spontaneous behaviors, emotions, or thoughts. This term was first
used to describe the symptoms of neurologically impaired patients with frontal
lobe brain damage who exhibited infrequent speech, passivity, and emotional
unresponsiveness Uackson, 1984). The concept of negative symptoms was sub-
sequently applied to a subgroup of patients with schizophrenia who had severe
deficits in social, emotional, and cognitive functioning, but often lacked promi-
nent active positive symptoms of psychosis. A useful construct is to consider
this cluster of symptoms as consisting of the five A's of negative symptoms in
schizophrenia:
• Blunted or flat affect (lack of emotional expression)
• Alogia (reduced amount of speech or poverty of content)
• Asociality (social withdrawal)
• Apathy (lack of interest or spontaneity or psychomotor retardation).
• Attentional impairment (difficulty concentrating or performing sequen-
tial tasks)
Severe negative symptoms have been shown to be relatively stable over time
(R. R. J. Lewine, 1990; Mueser, Douglas, Bellack, & Morrison, 1991; Mueser, Say-
ers, Schooler, Mance, & Haas, 1994) and strongly associated with poor social
functioning (Bellack, Morrison, Wixted, & Mueser, 1990). Negative symptoms are
also typically the most resistant to treatment, although the newer atypical anti-
psychotic medications (e.g., clozapine) have a greater effect on negative symp-
toms compared to traditional agents (Salzman, Vaccaro, & Lief, 1995).
In addition to positive and negative symptoms, schizophrenia can also in-
clude affective symptoms. One important affective symptom in schizophrenia
is depression. Postpsychotic or secondary depression occurs after 25% of acute
schizophrenic episodes, and approximately 60% of individuals with schizo-
phrenia suffer a major depression at some time during the course of their ill-
ness. Depression is associated with poor outcomes, including increased rate of
relapse, longer duration of hospitalization, poorer response to pharmacological
treatments, and chronicity (Bartels & Drake, 1988). In addition, suicide is a cat-
astrophic outcome associated with depression in schizophrenia. Approxi-
mately 50% of persons with schizophrenia attempt suicide at some time during
their lives, with a 10% rate of mortality (Roy, 1986).
Identification of specific subtypes and causes of depression in schizophre-
nia is a critical step in evaluating appropriate treatment alternatives. Elsewhere,
we have postulated three broad subtypes to describe depression in schizophre-
nia: depressive symptoms secondary to organic factors (e.g., medication side ef-
Schizophrenia 177
fects, alcohol and substance abuse, medical disorders); depressive symptoms

associated with acute psychosis; and depressive symptoms in chronic states, in-
cluding secondary major depression, negative symptoms, chronic demoraliza-
tion, and prodromal precursors to acute psychotic episodes (Bartels & Drake,
1988). Identifying the specific subtype of depression is critical in determining
and implementing effective treatment approaches (Bartels & Drake, 1989).
Late-Onset Schizophrenia
The diagnosis of late-onset schizophrenia evolved from early descriptions

of a disorder called paraphrenia. Kraepelin (1919/1971) used the term para-
phrenia to describe a group of older patients with symptoms similar to demen-
tia praecox, but with fewer negative and cognitive symptoms. Kay and Roth
(1961) later described "late paraphrenia" as a paranoid syndrome occurring in
late life that was not accompanied by co-occurring dementia. Late paraphrenia
was characterized by an onset after age 45 of a well-organized paranoid delu-
sional system, with or without auditory hallucinations, and it often occurred
with preserved personality (Herbert & Jacobson, 1967). More recently, psychi-
atric diagnostic criteria have been revised to reclassify most individuals for-
mally diagnosed with late paraphrenia as having late-life schizophrenia. For
example, recent revisions of the Diagnostic and Statistical Manual of Mental
Disorders allow for a diagnosis of schizophrenia with the first onset of symp-
toms after age 45 (e.g., American Psychiatric Association, 1994).
Symptoms of LOS typically include relatively well-circumscribed, nonbizarre
delusions without a formal disorder in thought processes. In most instances, the
individual with LOS exhibits speech and thought processes that are indistin-
guishable from other older adults who do not have a major mental illness. In con-
trast, many individuals with EOS display disorganized speech symptomatic of a
prominent underlying thought disorder. Delusions and hallucinations are also
common symptoms in late-onset schizophrenia, and occur at a rate comparable to
those found in adults with early-onset schizophrenia. Delusions tend to be para-
noid and are often systematized (Almeida, Howard, Levy, & David, 1995a, 1995b;
Howard, Castle, Wessely, & Murray, 1993; Kay & Roth, 1961). Auditory hallucina-
tions are substantially more common than visual or somatic hallucinations, simi-
lar to young adults with EOS (Almeida et aJ., 1995a, 1995b). In contrast to EOS,
LOS is significantly less likely to manifest formal thought disorder, negative symp-
toms, or inappropriate affect (Almeida et aJ., 1995a, 1995b; Howard et al., 1993;
Kay & Roth, 1961; Pearlson & Rabins, 1988; Pearlson et al., 1989).
In the diagnosis of late-onset schizophrenia, one should consider a variety
of alternatives. Other disorders should be ruled out before assigning a diagnosis
of LOS. For example, special consideration should be given to ruling out psy-
chiatric disorders secondary to medical causes (formerly organic mental disor-
ders), major affective disorders, and delusional (paranoid) disorders (Harris &
Jeste, 1988). As previously discussed, medical disorders can present with
symptoms of psychosis that are entirely caused by the underlying medical
illness. Major affective disorders, including bipolar disorder and delusional
depression, can also mimic signs and symptoms of late-onset schizophrenia.
178 Stephen J. Bartels et 01.
Delusional disorder shares some characteristics with LOS but can be differen-
tiated by the presence of prominent nonbizarre delusions and nonprominent (or
absent) hallucinations. Nonbizarre delusions, for example, involve situations
that may occur in real life, such as being poisoned, followed, having a disease,
or being deceived by a spouse or lover. In contrast, bizarre delusions involve
phenomena that are considered totally implausible within one's culture, such
as being possessed by aliens or having one's thoughts or actions controlled by
implanted electronic devices (American Psychiatric Association, 1994; Yassa
& Suranyl-Cadotte, 1993). Individuals with LOS are more likely to show better
premorbid occupational adjustment and higher marriage rates compared to
those with EOS (Post, 1966). However, individuals with LOS may have schizoid
or paranoid premorbid personalities and are frequently socially isolated com-
pared to normal comparison groups (Kay & Roth, 1961; Harris & Jeste, 1988).
A final symptom associated with LOS is the presence of sensory impair-
ment that appears to predate onset of the disorder. In a review of 27 articles
evaluating visual and hearing abilities in elderly with late-onset disorders,
Prager and Jeste (1993) found that sensory deficits are overrepresented in the el-
derly LOS population. A specific relationship between visual impairment and
late-onset paranoid psychosis remains controversial. although an association
between visual impairment and visual hallucinations is suggested by the liter-
ature. On the other hand, the literature does support an association between
hearing deficits and late-onset paranoid psychosis. Approximately 40% of
those with late-onset paranoid psychoses have been found to have moderate to
severe hearing deficits (Kay & Roth, 1961; Herbert & Jacobson, 1967). It is pos-
sible that deafness may precipitate or exacerbate symptoms, since significant
reductions in psychotic symptoms have been reported for some individuals
with late-onset paranoid disorders after being fitted with a hearing aid
(Almeida, FCirstl, Howard, & David, 1993).
Gender and Age of Onset
Differences have been found between men and women in a number of ar-
eas related to onset and course of schizophrenia. R. J. Lewine (1988) found that
mean age of onset of schizophrenia in women is approximately 5 years later
than in men, a finding consistent with many other studies documenting a later
age of onset of schizophrenia for women (Hafner et aJ., 1993). In a comprehen-
sive review of the literature, Harris and Jeste (1988) found that virtually all
studies report a greater proportion of women than men with late-onset schizo-
phrenia, with the ratio of women to men ranging from 1.9:1 to 22.5:1. In con-
trast, most studies of EOS report similar proportions of women to men. Several
explanations for this difference have been proposed. One view suggests that
EOS and LOS are different forms of schizophrenia with different characteris-
tics, including different rates among men and women. An alternative view sug-
gests that biological factors are responsible for a later onset of schizophrenia in
women, resulting in an overrepresentation of women compared to men for LOS.
In a community study which included EOS and LOS, D. J. Castle and Murray
(1993) found that 16% of males had the onset of schizophrenia after age 45,
Schizophrenia 179
compared with 38% of females. Speculation about the difference in age of on-
set between men and women includes a possible protective effect of estrogens
or a precipitating effect of androgens (D. J. Castle & Murray, 1993).
J. M. Goldstein (1988) and Seeman (1986) suggest that male gender, by it-
self, may represent a risk factor to poorer outcome in schizophrenia. Possible
explanations for increased risk include biological causes such as differences in
male and female brain structure (R. R. J. Lewine, Gulley, Risch, Jewart, & Houpt,
1990), or differences in protective hormonal levels such as estrogen (Seeman &
Lang, 1990). An alternative explanation suggests that comorbid disorders. such
as substance abuse, that are more prevalent in men result in poorer functioning
and outcomes for men compared with women. Substance abuse has been asso-
ciated with a variety of poor outcomes, including increased use of hospitalization
and emergency services (Bartels et 01., 1993), aggressive and hostile behaviors
(Bartels, Drake, Wallach, & Freeman, 1991), and housing instability and home-
lessness (Drake, Osher, & Wallach, 1989). Prevalence of comorbid substance use
disorders diminishes over time. yet these disorders continue to be important
risk factors in older mentally ill patients (Bartels & Liberto, 1995). Finally, dif-
ferences in social support and social skill between men and women with schiz-
ophrenia may be associated with better outcomes. Women with schizophrenia
are more likely to marry (Test & Berlin, 1981), are more likely to maintain con-
tact with their children (Test, Burke, & Wallisch, 1990), and hence may tend to
have stronger family social networks compared with men with schizophrenia.
Mueser and associates (1990) found that women with schizophrenia are more
socially skilled than men, perhaps leading to less social isolation and better
functioning in the community.
KEY FACTORS AFFECTING TREATMENT

OUTCOMES IN OLDER ADULTS
WITH SCHIZOPHRENIA
The Role of Cohort
An important factor in considering different functional outcomes for elderly

persons with schizophrenia is the "cohort effect." The concept of cohort reflects
the fact that individuals born at a particular time share a unique set of historical
experiences. Most importantly, these individuals experienced these events at a
similar point in their life cycle. In this respect, cohort effect is the product of an
interaction between the age and the historical period resulting in common ex-
periences of key life events (Fischer, 1996). For the older person with schizo-
phrenia, there are dramatic differences in life and treatment experience among
those who entered the treatment system before the mid-1950s and those first
treated after 1960. Before 1955, antipsychotic medications were not available
and the standard treatment for severe and persistent psychotic illness was long-
term hospitalization in mental asylums. Many individuals entering the state
hospital system before this time were hospitalized for decades. In the 1960s use
of antipsychotic medications became widespread, and a wave of mental health
care reform resulted in deinstitutionalization of many individuals in the state
180 Stephen J. Bartels et al.
hospital system, and the development of community mental health services. For
the older patient with schizophrenia, these two experiences of the treatment sys-
tem had dramatic long-term effects on functional and symptom outcomes.
The Institutionallreatment Cohort

Among the elderly who currently have schizophrenia are a group of indi-
viduals who are severely functionally impaired and who remain in long-term
care units in state mental hospitals or nursing homes. Three factors are likely to
be associated with their poor long-term outcomes. First, this group of individu-
als became ill before development of antipsychotic medication. Extensive re-
views of outcome studies suggest that treatment with antipsychotic medication
results in acute symptom improvement and long-term benefits in better out-
comes (Hogarty et al., 1986; Wyatt, 1991). Recent studies on first-onset psy-
chosis also suggest that treatment occurring in the early stages of severe
psychotic disorders may result in better long-term outcomes (Szymanski,
Canaan, Gallacher, Erwin, & Gur, 1996). Second, it is likely that long-term in-
stitutionalization results in poor social skills. severe limits in functional abili-
ties, and loss of social supports outside of the institutional setting. Independent
living skills may become atrophied, with substantial dependence on care
providers for basic needs.
Third, although many of the chronic deficits common in these individuals
have been attributed to long-term institutionalization, it is likely that some in-
dividuals who remain in institutions are among the most severely mentally ill
and have the most intractable and disabling form of the illness. These individ-
uals may have been considered too ill to be discharged to community settings.
For example, Ciampi (1980) found that long-term outcome of schizophrenia
was characterized by severe functional deficits and symptoms for one third of
the individuals. Some of these individuals remain in state hospitals (Davidson
et al., 1995), while others have been "transinstitutionalized" to nursing homes.
Elderly schizophrenic patients who continue to require treatment in late life in
nursing homes, compared to those in the community, were more severely im-
paired, both functionally and physically, and had more severe negative symp-
toms, cognitive impairment, and behavioral problems (Bartels, Miles, Dain, &
Smyer, 1998). Regardless of the cause of these more severe symptoms and func-
tional problems, little is known about the potential for rehabilitation for persis-
tently institutionalized individuals.
The Community 1i'eatment Cohort

In contrast to older individuals with schizophrenia who have been chroni-
cally institutionalized, a more recent and younger group of aging patients with
severe mental illness entered the treatment system in an era of antipsychotic
medication treatment and a declining use of institution-based care. These indi-
viduals are the "young-old" (in their 60s) and were among the first wave of se-
verely mentally ill patients who became ill when states were closing their
long-term wards and shifting treatment into the community. Some of these indi-
viduals were beneficiaries of early forms of community support and psychoso-
Schizophrenia 181
cial rehabilitation services (Harding et 01., 1987a. 1987b). Others undoubtedly

gained experience in developing adaptive coping and living skills through the
assistance of family members or other social supports. Many of these individu-
als reside in the community with little or no need of mental health services.
However, a substantial minority of older individuals with schizophrenia in
the community remains highly symptomatic and still has substantial difficul-
ties in many areas of functioning (Bartels, Mueser. Miles. 1997). Compared to
older adults with other mental disorders, these patients use considerably
greater and different types of mental health services (Bartels et 01., 1998). Com-
prehensive community support services and social supports appear to be es-
sential to assisting many of these more severely impaired individuals in living
in the community.
The Importance of Family and Social Supports
One of the major differences between older individuals with severe men-
tal illness residing in the community. compared with those in nursing homes
and other institutions, is the presence of family and social supports (Meeks et
aI., 1990). Persons with schizophrenia are less likely to marry. are less likely to
have children, and are less likely to work compared with persons without a se-
vere psychiatric disorder. Social networks of persons with schizophrenia tend
to be smaller than those of normal subjects and tend to diminish with age (Co-
hen, 1995). Thus, many older adults with schizophrenia do not have the sup-
ports that are often available to older persons without severe mental illness who
reside in the community with the assistance of family members. The literature
on family supports is also replete with reports of aging parents (usually moth-
ers) caring for their middle-aged children with schizophrenia (e.g., Bulger, Wan-
dersman, & Goldman, 1993; MacGregor, 1994; Platt. 1985) or supplementing
financial resources (Salokangas, Palo-Oja, & Ojanen. 1991). The aging and even-
tual death of parents who are key supports places these individuals at risk for
decompensation and loss of ability to continue to reside in individual place-
ment in the community. When the parent becomes ill or dies. the offspring, fre-
quently in his or her forties. must become accustomed to a dramatic reduction
in financial and social support, which may also coincide with, or directly result
in, a loss of residence. The need to bolster family capacity and social supports
is an important component to consider in service planning.
The Older Adult With Schizophrenia and Antipsychotic Medications
Older persons are especially sensitive to the adverse side effects of med-
ications; therefore, careful attention is required in choosing the appropriate
type and dosage of medication. For example, age and duration of exposure to
antipsychotic medications are extensively documented as primary risk factors
for the development of tardive dyskinesia (J. Kane et 01., 1992). Tardive dyski-
nesia is a neurological syndrome characterized by persistent abnormal invol-
untary movements. Annual incidence rate of tardive dyskinesia in elderly with
schizophrenia is 26% to 45%, depending on the criteria for tardive dyskinesia

that are applied (Jeste, Lacro, Gilbert. Kline. & Kline. 1993). The more conserv-
ative estimate of 26% is nearly six times the rate reported for younger patients
(J. Kane, Woerner, & Lieberman. 1988). Other common side effects of antipsy-
chotic medications include extrapyramidal side effect. such as medication-
induced Parkinson's syndrome (akinesia) and akathisia. Akinesia is character-
ized by muscle rigidity, shuffling gait, lack of spontaneous facial expressions,
and severe resting tremor of the arms, hands, head. and legs. Akathisia is char-
acterized by severe restlessness or pacing behavior. Older adults may be more
vulnerable to all of these side effects due to greater sensitivity to lower doses of
medication and co-occurring neurological disorders. Aging is associated with
increased prevalence of extrapyramidal nervous system side effects (EPS) due
to biological changes in neuroreceptor sensitivity and declining amounts of
dopamine occurring with age. Hence, ongoing, close monitoring of side effects
and neurological status is imperative.
More recently, alternatives to standard antipsychotic medications have be-
come available that have reduced (or negligible) risk of extrapyramidal side
effects. These atypical antipsychotic agents include medications such as cloza-
pine, risperidone, and olanzapine. Initial trials of the class of agents in elderly
patients with psychotic symptoms are promising, with evidence supporting
their effects on both positive and negative symptoms (Salzman et al., 1995).
Clozapine was the first of these agents and has been limited by a variety of side
effects such as excess sedation, positional hypotension (low blood pressure),
and the need to closely monitor potentially life-threatening side effects such as
agranulocytosis (dramatic decreases in white blood cell count) and sponta-
neous seizures. But it is also the only atypical antipsychotic medication that
does not appear to cause tardive dyskinesia. Fortunately, the newer atypical
agents risperidone and olanzapine appear to be safer and easier to monitor,
while maintaining many of the benefits of clozapine (Pickar. 1995).
The Interaction of Psychiatric and Medical Illness-Comorbidity
Comorbidity is one of the major characteristics distinguishing the older

person with schizophrenia from younger individuals with the disorder.
Whereas younger patients have symptoms that often can be understood on the
basis of a single disorder, the older patient with schizophrenia typically pre-
sents with multiple problems resulting from their symptoms and functional dis-
abilities (Moak, 1996). These comorbid disorders include co-occurring medical
illness and dementia.
Serious health problems are common in schizophrenia and are often undi-
agnosed and undertreated (Cohen, 1993). Often, people with schizophrenia are
more likely to have difficulty obtaining medical services and are more likely to
receive poor care (Koran et aJ., 1989; Koranyi, 1979). Emerging medical prob-
lems may be misinterpreted as a worsening of psychiatric symptoms. For ex-
ample, symptoms of agitated or bizarre behavior may be due to worsening
physical pain or delirium. Symptoms of depression may be caused by thyroid
hormone deficiency or an occult carcinoma. Common medical conditions af-
fecting older patients include hypertension, heart disease, arthritis. diabetes,
Schizophrenia 183
chronic lung disease, anemia, gastrointestinal disease, and neurological disor-

ders including stroke, movement disorders, and seizure disorders. Worsening of
psychiatric symptoms may be the first signs of underlying medical illness.
Just as medical disorders can cause or exacerbate psychiatric conditions, the
converse may also be true. A worsening of psychotic symptoms may precipitate
a deterioration in medical function. For example, an acute psychotic episode in
a patient with brittle diabetes may result in failure to adhere to scheduled in-
sulin injections, dietary restrictions, and adequate hydration, causing a severe
and potentially life-threatening decompensation. In addition, the older patient
with severe psychiatric symptoms may have difficulty communicating their
medical concerns and may refuse needed medical evaluations and procedures.
Behavioral problems, including severe social withdrawal, negativism, and ag-
gression, can make it extremely difficult for medical providers to conduct ap-
propriate physical examinations, medical tests, and treatments (Moak, 1990).
Other factors that contribute to poor physical health include health-dam-
aging behaviors such as smoking (Hughes, Hatsukami, Mitchell, & Dahlgren,
1986), substance abuse (Bartels & Liberto, 1995), limited access to good health
care because of financial constraints, and a delay in seeking medical treatment
as a result of possible differences in pain threshold found in some persons with
schizophrenia (Dworkin, 1994). Mortality rates in persons with schizophrenia
are higher than nonpsychiatric comparison groups (M. T. Tsuang, Woolson, &
Fleming, 1980). In addition to relatively high rates of suicide (Drake, Gates,
Whitaker, & Cotten, 1985), the physical health of many persons with schizo-
phrenia is similar to those much older (Mulsant et 01., 1993). Thus, assessment
of physical health and the adequacy of their health care services are critical el-
ements in the assessment of older persons with schizophrenia.
Another important factor that can complicate diagnosis and treatment in
older adults is the development of co-occurring cognitive impairment disorders
in late life. Several studies suggest that a subset of individuals with schizo-
phrenia is prone to develop dementia in late life (Davidson et 01, 1995; Lesser et
01., 1993), although the cause and prevalence of dementia in schizophrenia is
controversial (Goldberg, Hyde, Kleinman, & Weinberger, 1993; Heaton et 01.,
1994). For individuals in the community, comorbid cognitive impairment is as-
sociated with substantially higher use of psychiatric services and community
supports (Bartels et aI., 1998). When cognitive impairment becomes severe,
symptoms of dementia can overshadow the psychosis and become the primary
source of functional impairment in late life. For these individuals a supported,
supervised setting becomes a necessity, and without the availability of 24-hour
care, nursing home care may be unavoidable (Moak, 1996).
A TREATMENT APPROACH TO
SCHIZOPHRENIA IN OLDER ADULTS:
THE BIOPSYCHOSOCIAL MODEL
Remarkably little is known about effective treatments for the older person
with schizophrenia, although potential directions are suggested by longitudinal
outcome studies and by studies of younger patients with the disorder. Longitu-
dinal studies have shown that the course of schizophrenia is usually episodic,
with some residual impairment between exacerbations. However, there is a

trend for gradual improvement and, in some cases, total remission later in life
(Ciompi, 1980; Harding et a1., 1987a, 1987b). Long-term studies of the natural
history of schizophrenia suggest that the first ten years of the illness are marked
by exacerbations and remissions, but symptoms substantially remit in more
than half of the individuals with schizophrenia in later life.
This improvement likely is a result of many factors. For example, biologi-
cal changes, such as age-related decreases in the neurotransmitter dopamine,
may result in symptom reductions. In addition, individuals may acquire illness
management skills, such as strategies for reducing stress and improving symp-
tom recognition and medication compliance (Herz, 1985). Other factors include
reduction in substance use with age that can improve patients' symptoms and
level of functioning (Zisook et a1., 1992). Overall, there is greater optimism for
favorable long-term outcomes for many individuals afflicted with schizophre-
nia, although a subgroup remains that continues to require intensive treatment
and supervision in late life.
Treatment of schizophrenia in late life is best considered within the frame-
work of a biopsychosocial perspective. This perspective posits that biological,
psychological, and social aspects of the person must be considered for an opti-
mal assessment and treatment. This three-pronged approach is essential for the
older person with schizophrenia. First, the older person commonly has multi-
ple medical problems and is likely to be on a number of different medications
that can substantially complicate assessment and treatment. Biological changes
associated with aging directly affect medication metabolism and result in a
higher prevalence of medication side effects and interactions with other drugs.
Second, the psychological impact of mental illness and the effects of aging must
be carefully weighed in designing a treatment program. The individual's cogni-
tive abilities must be comprehensively assessed in order to inform the choice of
intervention. Prior history of mental illness, psychological strengths, and emo-
tional vulnerabilities need to be systematically evaluated. Finally, social sup-
ports and stressors are a major consideration in assessing needed services. One
of the most important factors determining whether an older person with schiz-
ophrenia remains in the community or permanently resides in a nursing home
is the presence of social and instrumental supports (Meeks et a1., 1990). In sum-
mary, the biopsychosocial perspective should be the foundation to ensure a
comprehensive clinical assessment and effective plan of treatment. In the fol-
lowing section, we summarize biological and psychosocial approaches to treat-
ment developed and studied largely in younger populations but adapted for
older persons with schizophrenia.
Biological Treatment
Virtually any psychiatric symptom can be caused or exacerbated by an un-

derlying medical illness (Bartels, 1989), underscoring the importance of an ini-
tial thorough medical evaluation in the biological treatment of the older adult
with schizophrenia. The underdiagnosis of medical disorders among individu-
als with severe mental illness necessitates a careful review of current physical
Schizophrenia 185
complaints and health status. Adequate assessment and treatment can be espe-
cially challenging when complex physical problems occur in individuals who
are delusional, cognitively impaired, lacking in social or communication skills,
or physically threatening (Moak, 1996). Nonetheless, comorbid medical illness
must be thoroughly assessed in order to address symptoms that may be caused
or exacerbated by medical conditions or medication toxicity.
There are few data on the pharmacological treatment of elderly with schiz-
ophrenia (Jeste et a1., 1993; Jeste et al., 1996). A review of the few available
studies states that most report that antipsychotic medications result in a reduc-
tion of symptoms and earlier discharge from the hospital (Jeste et a1., 1993). Ef-
ficacy of antipsychotic medications for patients with schizophrenia has been
demonstrated in numerous controlled studies. Older adults with LOS have
been shown to be as responsive to antipsychotic medications as young patients
with schizophrenia when treated with appropriate agents and dosages. For ex-
ample, response rates of late-onset schizophrenia to antipsychotic medications
range from 62% (Post, 1966) to 86% (Rabins. Pauker, & Thomas, 1984).
Antipsychotics serve two primary purposes in the treatment of schizo-
phrenia. First, they reduce acute symptoms that appear during an exacerbation,
including both positive and negative symptoms (J. M. Kane & Marder, 1993).
Second, administration of anti psychotics lowers the probability of subsequent
relapses by 30% to 60% (J. M. Kane, 1989). Low doses of antipsychotic med-
ication have been shown to be effective at lowering risk of relapse (Van Putten
& Marder, 1986), suggesting that it is possible to reduce patients' vulnerability
to long-term side effects ofthese medications (e.g., tardive dyskinesia). Also, re-
cent improvements in the development of atypical antipsychotic medications
(e.g., clozapine, risperidone, olanzapine), have shown that the functioning of
patients who are treatment refractory to the standard antipsychotics can be im-
proved (Meltzer, 1990, 1994; Pickar, 1995; Jeste et a1., 1996).
Physiological changes of aging contribute to increased risk of acute adverse
side effects to antipsychotic medications in the elderly. Age-related alterations
in drug distribution and metabolism may result in higher plasma levels of an-
tipsychotic medications in elderly compared to younger schizophrenic pa-
tients. In addition, age-related changes in receptors and neurotransmitters may
cause elderly patients to be more sensitive to the effects of medications. Hence,
effective serum levels of medication in elderly patients are achieved with sub-
stantially lower doses of antipsychotic medication.
Because age is associated with remission of symptoms in more than half of
individuals with schizophrenia (Harding et a1., 1987a, 1987b), some elderly in-
dividuals may be spared the risks of continued exposure to antipsychotic med-
ications. Jeste and colleagues (1993) reviewed six double-blind studies of
antipsychotic drug withdrawal followed for a mean of 6 months in older adults
with schizophrenia and found an average relapse rate of 40%, compared to a re-
lapse rate of 11 % for those who continued on medication. The authors con-
cluded that stable, chronic outpatients without a history of antipsychotic
discontinuation should be considered for a carefully monitored trial of an-
tipsychotic withdrawal. In summary, although the need remains for effective
psychosocial interventions for schizophrenia, antipsychotic medications con-
tinue to be the mainstay in all treatment programs for schizophrenia.
Psychosocial Interventions
The stress-vulnerability model for schizophrenia offers one approach to

understanding the role of psychosocial treatment (Liberman, Mueser, Wallace,
Jacobs, et aI., 1986; Nuechterlein & Dawson, 1984). In this model, biological
vulnerability, psychological coping, and environmental stress contribute in
combination to the presence and severity of schizophrenic symptoms. Genetic
and other biological factors are thought to determine biological vulnerability
early in life, whereas environmental stressors may include exposure to high lev-
els of negative emotion, life events such as the death of a significant other, and
an absence of structure or support. Stressful life events can directly contribute
to psychotic relapse in schizophrenia (Ventura, Nuechterlein, Lukoff, & Hard-
esty, 1989). Coping and living skills can help to offset an underlying psycho-
logical vulnerability to stress.
The stress-vulnerability model calls for an approach to treatment consist-
ing of (1) reducing vulnerability, (2) reducing environmental stress, and (3) en-
hancing coping skills. For example, biological vulnerability can be lessened by
providing antipsychotic medications and decreasing substance abuse. Individ-
ual treatment approaches, such as social skills training (Liberman. DeRisi, &
Mueser, 1989) tend to focus mainly on improving patients' coping skills,
whereas psychosocial interventions, such as family interventions. are directed
toward a reduction of environmental stress (Mueser & Glynn, 1995; Tarrier et
a1., 1988). Most treatments for schizophrenia share one or more of these goals.
Social skills training has not been evaluated in older patients with schizo-
phrenia, but effectiveness of this approach for younger individuals suggests that
it may have a role in psychosocial treatment of elderly with severe mental ill-
ness. The fundamental premise of social skills training is that the social im-
pairments of schizophrenia can be decreased through systematically teaching
the behavioral components of social skills (Bellack & Mueser, 1993; Bellack,
Thrner, Hersen, & Luber, 1984; Dobson, McDougall, Busheikin, 1995; Liberman,
Mueser, & Wallace, 1986; Marder et aI., in press). Many individuals with schiz-
ophrenia require outpatient interventions, such as social skills training, that
can be provided on a group or individual basis (Taylor & McDowell, 1986).
These skills can be learned through a combination of therapist modeling (i.e.,
demonstration ofthe skill), patient behavioral rehearsal (i.e., role playing), pos-
itive and corrective feedback, and homework assignments. Subsequently, clin-
icians and family members can assist the individual in generalizing these skills
to the natural environment. Targeted social skills span a wide range of adaptive
interpersonal and self-care behaviors, including the expression of feelings, con-
flict resolution skills, and medication management.
Overall, controlled studies on social skills training for schizophrenia provide
some support for its efficacy, especially when treatment is provided over the long
term (Mueser, Wallace, & Liberman, 1995). It is clear that skills training can im-
prove social skills, and there is some evidence supporting its effect on social func-
tioning. The impact of social skills training on the symptoms of schizophrenia is
less clear, but it remains an important avenue for improving social functioning.
Family interventions directed toward reduction of environmental stress
and enhancement of adaptive behaviors can also be important in reducing the
Schizophrenia 187
risk ofrelapse in individuals with schizophrenia (Tarrier et 01 .. 1988). As insti-

tutionallong-term care becomes rare, family interventions have taken on in-
creasing importance. Several studies have demonstrated that a stressful family
environment is associated with increased rates of relapse (Brown, Birley, &
Wing, 1972; Vaughn & Leff, 1976; Vaughn, Snyder, Jones, Freeman, & Falloon,
1984; see Kavanagh, 1992). In particular, relapse has been associated with liv-
ing environments where there are higher levels of critical comments, hostility,
overinvolvement or "expressed emotion" (EE). Although high EE may playa
role in precipitating relapse, it is also likely that living with a relative with fre-
quent psychotic relapses may result in family caregivers' experiencing in-
creased levels of stress, resulting in high EE (Glynn et 01., 1990). In either case,
the treatment literature establishes that family-based interventions can have a
significant, positive impact on many patients with schizophrenia and, fre-
quently, on their relatives as well (I. Falloon et 01., 1982; Hogarty et 01., 1986;
Leff, Kuipers, Berkowitz, Eberlein-Weis. & Sturgeon, 1982; Randolph et 01.,
1994; Xiong et 01 .. 1994). Unfortunately, these studies have largely focused on
younger patients with severe mental illness (generally with older parent care
providers), and implications of this technology for the older patient with schiz-
ophrenia are unknown, particularly as the dynamic between family and patient
is complicated by the medical deficits of the older adult.
Another focus of family-based treatment are interventions that enhance the
coping skills of caregivers (e.g., Abramowitz & Coursey, 1989; Solomon, Draine,
Mannion, & Meisel, 1996a, 1996b). Within the general population, one in six
adults provide care to aging parents. In general, adult daughters are most likely
to become care providers, with the average American woman spending 18 years
helping aging parents (Stone & Kemper, 1989). The burden of caring for an ag-
ing parent or spouse has been associated with clinical depression and anxiety
disorders, increased use of psychotropic medications, and increased stress-
related disorders including immunological dysfunction, in addition to the cost
oflost income and other opportunities (Cohen, 1993; Eisdorfer, 1991; Wright,
Clipp, & George, 1993). The inability of family care providers to cope with the
care needs of aging parents is a major risk factor for eventual placement of the
older individual in a long-term care institutional setting.
One means of delaying nursing home placement may be through direct in-
terventions that enhance the coping skills and support of spouse-caregivers. For
example, Mittelman and colleagues (Mittelman, Ferris. Shulman, & Steinberg,
1996) conducted a randomized trial consisting of 206 spouse caregivers of
Alzheimer's disease to assess the effectiveness of six sessions of individual and
family counseling followed by support groups over 31/2 years. Alzheimer pa-
tients in the intervention group had a community tenure 329 days longer than
the control group, with control group spouses being two thirds as likely to place
their spouses in a nursing home at any time. This type of community-based in-
tervention developed for family care providers of patients with Alzheimer's de-
mentia may hold promise in the treatment of the older patient with severe
mental illness, who may present significant challenges in late life to the family
care provider.
Finally, there is also an important role for direct interventions to enhance
coping skills in the person who has schizophrenia. A growing body of evidence
has emerged that patients with schizophrenia employ a wide range of different
strategies for coping with positive and negative symptoms. Coping efficacy ap-
pears to be strongly related to the number of coping strategies employed by the
patient (Carr, 1988; Falloon & Talbot, 1981; Mueser, Valentiner, & Agresta, in
press). Over the process of growing older, many individuals learn ways to cope
with symptoms and psychosocial stressors though trial and error (Wing, 1987).
Observed strategies include use of positive self-talk (to overcome unwanted
thoughts), meditation, relaxation techniques, and engaging in distracting activ-
ities (Brier & Strauss, 1983; Cohen & Berk, 1985). Individuals with schizophre-
nia may benefit from systematic instruction in coping strategies. For example,
Tarrier and colleagues (1993) found that patients with residual psychotic symp-
toms who were taught coping strategies experienced significant reductions in
positive symptoms compared with patients who received training in problem-
solving skills.
Overall, data on psychosocial interventions come largely from studies on
younger patients. However, it is evident from the literature on older adults with
schizophrenia that there is a substantial need for treatment approaches that ad-
dress the considerable psychosocial needs of older patients and their families.
Many of these approaches appear well suited to the older person and should be
adapted and tested in clinical settings.
SUMMARY
Although schizophrenia among younger adults is a seriously debilitating

disorder that has received considerable study, remarkably little is known about
factors affecting the course or outcome of schizophrenia in older adults (Belit-
sky & McGlashan, 1993). Recent studies have begun to advance the base of
knowledge on the phenomenology and treatment of schizophrenia in late life.
Schizophrenia in late life can be part of a life-long illness (early-onset schizo-
phrenia), or may first appear in older age (late-onset schizophrenia). Individu-
als with late-onset schizophrenia experience symptoms similar to those of
early-onset schizophrenia, yet are more likely to report better premorbid func-
tioning and exhibit fewer negative symptoms or symptoms of formal thought
disorder. Treatment studies suggest that response to antipsychotic medication
for LOS is comparable to that in early-onset schizophrenia. For either disorder,
use of low dosages and trials of the newer atypical antipsychotic medications
are likely to be preferred, as the risk of adverse side effects such as tardive dys-
kinesia and acute extrapyramidal side effects increases substantially with age.
The long-term outcome of schizophrenia is favorable for most individuals,
yet outcomes are heterogeneous across individuals. Several factors appear to be
especially important in the outcome of schizophrenia in late life. For older
adults with early-onset schizophrenia, the effect of treatment cohort may have
long-term consequences. The oldest of the old are likely to have spent many
years in institutional care, whereas younger treatment cohorts are likely to have
been exposed to antipsychotic medications early in the course of their illness
and have acquired independent living skills through the assistance of commu-
nity support and rehabilitation models of services. Comorbid medical illness
Schizophrenia 189
and comorbid cognitive impairment are common in older adults with schizo-
phrenia and require comprehensive medical assessment and specific attention
to develop the necessary services to address acute and long-term care needs as-
sociated with these disorders. Finally, treatment approaches to schizophrenia
in late life should follow from a biopsychosocial perspective. Appropriate use
of antipsychotic medications should consider the increased vulnerability to ad-
verse side effects and the potential advantages of the newer atypical antipsy-
chotic agents. Psychological approaches to treatment should be tailored to the
needs of the older adult and assist in developing coping and living skills that
support optimal functioning and quality of life. Social interventions are needed
that enhance the availability of social and family supports and the development
of adaptive social skills.
In spite of growing attention to the issues of aging, there is a paucity of re-
search on treatments and services for older persons with severe and persistent
mental illness. In particular, little attention has focused on the individual with
lifelong early-onset schizophrenia who is now in late middle age or old age. Fur-
ther research is needed to determine the most effective and appropriate pharma-
cological and psychosocial interventions for the older person with schizophrenia.
REFERENCES
Abramowitz, I. A., & Coursey. R. D. (1989). Impact of an educational support group on family par-
ticipants who take care of their schizophrenic relatives. Journal of Consulting and Clinical
Psychology. 57. 232-236.
Almeida. O. P.. Forst!. H .• Howard. R.. & David. A. S. (1993). Unilateral auditory hallucinations.
British Journal of Psychiatry. 162. 262-264.
Almeida. O. P.• Howard. R. J.. Levy, R.. & David. A. (1995a). Psychotic states arising in late life (late
paraphrenia): The role ofrisk factors. British Journal of Psychiatry, 166. 215-228.
Almeida. O. P.• Howard. R. J., Levy. R.. & David. A. (1995b). Psychotic states arising in late life (late
paraphrenia): Psychopathology and nosology. British Journal of Psychiatry. 166.205-214.
(4th ed.) Washington. DC: Author.
Bartels. S. J. (1989). Organic mental disorder: When to suspect medical illness as a cause of psychi-
atric symptoms. In J. M. Ellison (Ed.). Psychopharmacology: A primer for the psychotherapist
(pp. 205-239). Chicago: Year Book Medical Publishers.
Bartels. S. J., & Drake. R. E. (1988). Depressive symptoms in schizophrenia: Comprehensive differ-
ential diagnosis. Comprehensive Psychiatry. 29. 467-483.
Bartels. S. J.• & Drake. R. E. (1989). Depression in schizophrenia: Current guidelines to treatment.
Psychiatric Quarterly. 60. 333-345.
Bartels. S. J.• & Liberto. J. (1995). Dual diagnosis in the elderly. In A. F. Lehman & L. B. Dixon (Eds.).
Double jeopardy: Chronic mental illness and substance use disorders (pp. 139-158). Chur,
Switzerland: Harwood Academic.
Bartels. S. J.• Drake. R. E .• Wallach. M. A.. & Freeman. D. H. (1991). Characteristic hostility in schiz-
ophrenic outpatients. Schizophrenia Bulletin. 17. 163-171.
Bartels. S. J., Teague. G. B.• Drake. R. E .• Clark. R. E.• Bush. P.• & Noordsy. D. L. (1993). Service uti-
lization and costs associated with substance abuse among rural schizophrenic patients. Jour-
nal of Nervous and Mental Disease. 181,227-232.
Bartels. S. J., Miles, K. M .• Dain. B.• & Smyer. M. A. (1998). Community mental health service use by
elderly with severe mental illness. Manuscript under review.
Bartels. S. J.. Mueser. K. T.• & Miles. K. M. (1997). A comparative study of elderly patients with
schizophrenia and bipolar disorder in nursing homes and the community. Schizophrenia Re-
search, 27(2-3). 181-190.
Bartels, S. J., Mueser, K. T., & Miles, K. M. (1997). Functional impairments in elderly patients with
schizophrenia and major affective disorder living in the community: Social skills. living
skills, and behavior problems. Behavior Therapy, 28, 43-63.
Belitsky, R., & McGlashan, T. H. (1993). The manifestations of schizophrenia in late life: A dearth of
data. Schizophrenia Bulletin, 19,683-689.
Bellack, A. S., & Mueser, K. T. (1993). Psychosocial treatment of schizophrenia. Schizophrenia Bul-
letin. 19,317-336.
Bellack, A. S, Turner, S. M., Hersen, M., & Luber. R. F. (1984). An examination of the efficacy of so-
cial skills training for chronic schizophrenic patients. Hospital and Community Psychiatry,
35, 1023-1028.
Bellack, A. S., Morrison, R. 1., Wixted, J. T., & Mueser, K. T. (1990). An analysis of social compe-
tence in schizophrenia. British Journal of Psychiatry. 156, 809-818.
Bleuler, M. (1974). The long-term course of the schizophrenic psychoses. Psychological Medicine,
4,244-254.
Brier, A.M .. & Strauss, J. S. (1983). Self-control of psychotic behavior. Archives of General Psychia-
try, 40, 1141-1145.
Brown, G. W., Birley, J. L. T.• & Wing, J. K. (1972). Influence of family life on the course of schizo-
phrenic disorders: A replication. British Journal of Psychiatry, 121, 241-258.
Bulger, M. W., Wandersman, A., & Goldman, C. R. (1993). Burdens and gratifications of caregiving:
Appraisal of parental care of adults with schizophrenia. American Journal of Orthopsychiatry,
63, 255-265.
Carr, V. (1988). Patients' techniques for coping with schizophrenia: An exploratory study. British
Journal of Medical Psychology, 61, 339-352.
Castle. D.• Wessely, S.• Der, G., & Murray. R. (1991). The incidence of operationally defined schizo-
phrenia in Camberwell, 1965 to 1984. British Journal of Psychiatry. 159, 790-794.
Castle, D. J.• & Murray. R. M. (1993). The epidemiology of late-onset schizophrenia. Schizophrenia
Bulletin. 19,691-700.
Ciompi, L. (1980). The natural history of schizophrenia in the long term. British Journal of Psychi-
atry, 136,413-420.
Cohen, C. I. (1993). Poverty and the course of schizophrenia: Implications for research and policy.
Hospital and Community Psychiatry, 44,951-958.
Cohen, C. I. (1995). Studies on the course and outcome of schizophrenia in later life. Psychiatric
Services, 46, 877-889.
Cohen. C. I., & Berk.1. L. (1985). Personal coping styles of schizophrenic outpatients. Hospital and
Community Psychiatry. 36. 407-410.
Davidson, M., Harvey, P. D., Powchick, P., Parrella, M., White, L.. Knobler. H. Y., Losonczy. M. F..
Keefe, R. S., Katz, S.. & Frecska, E. (1995). Severity of symptoms in chronically institutional-
ized geriatric schizophrenic patients. American Journal of Psychiatry, 152, 197-207.
Dobson, D. J. G., McDougall. G., Busheikin, J.. & Aldous, J. (1995). Social skills training and symp-
tomatology in schizophrenia. Psychiatric Services, 46, 376-380.
Drake, R. E., Gates, C., Whitaker, A., & Cotten, P. G. (1985). Suicide among schizophrenics: A review.
Comprehensive Psychiatry, 26, 90-100.
Drake, R. E., Osher, F. C., & Wallach, M. A. (1989). Alcohol use and abuse in schizophrenia: A
prospective community study. Journal of Nervous and Mental Disease, 177, 408-414.
Dworkin, R. H. (1994). Pain insensitivity in schizophrenia: A neglected phenomenon and some im-
plications. Schizophrenia Bulletin, 20, 235-248.
Eisdorfer, C. (1991). Care giving: An emerging risk factor for emotional and physical pathology. Bul-
letin of the Meninger Clinic, 55, 238-247.
Falloon, I., Boyd, J., McGill, C., Razani, J., Moss, H., & Gilderman, A. (1982). Family management in
the prevention of exacerbations of schizophrenia. New England Journal of Medicine, 306,
1437-1440.
Falloon,l. R. H., & Talbot, R. E. (1981). Persistent auditory hallucinations: Coping mechanisms and
implications for management. Psychological Medicine, 11, 329-339.
Fischer, W. H. (1996). Mental health services for an aging population: What history cannot teach us
in planning for the twenty-first century. In S. M. Sorreff (Ed.), Handbook for the treatment of
the seriously mentally III (pp. 503-515). Seattle, WA: Hogrefe & Huber.
Schizophrenia 191
Glynn. S.. Randolph. E.• Eth. S.• Paz. G.• Shaner. A.• Strachan. A. (1990). Patient psychopathology
and expressed emotion in schizophrenia. British Journal of Psychiatry. 157. 877-880.
Goldberg. T. E.• Hyde. T. M.. Kleinman. J. E.. & Weinberger. D. R. (1993). Course of schizophrenia:
Neuropsychological evidence for a static encephalopathy. Schizophrenia Bulletin. 19.
797-804.
Goldstein. J. M. (1988). Gender differences in the course of schizophrenia. American Journal ofPsy-
chiatry. 145.684-689.
Gurland. B. J.• & Cross. P. S. (1982). Epidemiology of psychopathology in old age. Psychiatric Clin-
ics of North America, 5, 11-26.
Hafner. H.• Riecher-Rossler. A.• An der Heiden. W.• Maurer. K.. Fatkenheuer. B.• & Loffier. W. (1993).
Generating and testing a causal explanation of the gender difference in age at first onset of
schizophrenia. Psychological Medicine, 23, 925-940.
Harding, C. M.• Brooks. G. W.. Ashikaga. T.• Strauss. J. S .• & Breier. A. (1987a). The Vermont longi-
tudinal study of persons with severe mental illness. I: Methodology. study sample. and over-
all status 32 years later. American Journal of Psychiatry, 144, 718-726.
Harding. C. M.• Brooks. G. W.• Ashikaga. T.• Strauss. J. S .• & Breier. A. (1987b). The Vermont longi-
tudinal study of persons with severe mental illness. II: Long-term outcome of subjects who ret-
rospectively met DSM-UI criteria for schizophrenia. American Journal of Psychiatry, 144,
727-735.
Harris. M.• & Jeste. D. (1988). Late-onset schizophrenia: An overview. Schizophrenia Bulletin. 14.
39-55.
Heaton. R.. Paulsen. J. S .• McAdams. L. A.• Kuck. J.• Zisook. S .• Braff. D.• Harris. M. J.• & Jeste. D. V.
(1994). Neuropsychological deficits in schizophrenics: Relationship to age. chronicity. and de-
mentia. Archives of General Psychiatry. 51, 469-476.
Hegarty J. D.• Baldessarini. R. J.• Tohen. M.• Waternaux. C.• & Oepem. G. (1994). One hundred years
of schizophrenia: A meta-analysis of the outcome literature. American Journal of Psychiatry,
151.1409-1416.
Herbert. M.. & Jacobson. S. (1967). Late paraphrenia. British Journal of Psychiatry. 113.461-469.
Herz. M. I. (1985). Prodromal symptoms and prevention of relapse in schizophrenia. Journal of
Clinical Psychiatry. 46, 22-25.
Hogarty. G. E.• Anderson. C. M.• Reiss. D. J.• Kornblith. S. J.• Greenwald. D. P.. Javna. C.D .• & Mado-
nia. M. J. (1986). Family psychoeducation. social skills training. and maintenance chemother-
apy in the aftercare treatment of schizophrenia. I: One-year effects of a controlled study on
relapse and expressed emotion. Archives of General Psychiatry, 43. 633-642.
Howard. R.. Castle D.• Wessely. S .• & Murray. R. (1993). A comparative study of 470 cases of early-
and late-onset schizophrenia. British Journal of Psychiatry. 163, 352-357.
Huber. G.• Cross. G.• Schuttler. R.. & Linz. M. (1989). Longitudinal studies of schizophrenic patients.
Schizophrenia Bulletin, 6. 592-605.
Hughes. J. R.. Hatsukami, D. K.. Mitchell. J. E.. & Dahlgren. L. A. (1986). Prevalence of smoking
among psychiatric outpatients. American Journal of Psychiatry, 143.993-997.
Jackson. J. H. (1984). Remarks on the evolution and dissolution ofthe nervous system. Journal of
Mental Science, 33. 25-48.
Jeste. D. V.• Lacro. J. P.. Gilbert. P. L.• Kline. J.. & Kline. N. (1993). Treatment oflate-life schizophre-
nia with neuroleptics. Schizophrenia Bulletin. 19. 817-830.
Jeste. D. V.• Eastham. J. H.. Lacro. J. P.. Gierz. M.. Field. M. G.. & Harris. M. J. (1996). Management
of late-life psychosis. Journal of Clinical Psychiatry. 57(Supp. 3). 39-45.
Kane. J.• Woerner. M.• & Lieberman. J. (1988). Tardive dyskinesia: Prevalence. incidence. and risk
factors. Journal of Clinical Psychopharmacology. 8, 52-56.
Kane. J.• Jeste. D.• Barnes. T.• Casey. D.• Cole. J.• Davis. J.. Gualtieri. C.• Schooler. N .• Sprague, R.. &
Wettstein. R. (1992). Tardive dyskinesia: A task force report of the American Psychiatric As-
sociation. Washington. DC: American Psychiatric Association.
Kane. J. M. (1989). Innovations in the psychopharmacologic treatment of schizophrenia. In A. S.
Bellack (Ed.). A clinical guide for the treatment of schizophrenia (pp. 43-75). New York:
Plenum.
Kane. J. M.• & Marder. S. R. (1993). Psychopharmacologic treatment of schizophrenia. Schizophre-
nia Bulletin, 19,287-302.
Kavanagh. D. J. (1992). Recent developments in expressed emotion and schizophrenia. British Jour-
nal of Psychiatry, 160. 601-620.
Kay. D.• & Roth. M. (1961). Environmental and hereditary factors in the schizophrenias of old age
('late paraphrenia') and their bearing on the general problem of causation in schizophrenia.
Journal of Mental Science, 107, 649-686.
Koran, L. M., Sox, H. C., Marton, K. 1.. Molzen. S.. Sox. C. Hoo Kraemer. H. Coo Imai. Koo Kelsy. T. G.•
Rose, T. G., & Levin, L. C. (1989). Medical evaluation of psychiatric patients. Archives ofGen-
eral Psychiatry. 46.733-740.
Koranyi. E. K. (1979). Morbidity and rate of undiagnosed physical illnesses in a psychiatric clinic
population. Archives of General Psychiatry. 36. 414-419.
Kraepelin, E. (1971). Dementia praecox and paraphrenia (R. M. Barclay. Trans.). Huntington, NY:
Kreiger. (Original work published in 1919)
Leff, J., Kuipers. L.• Berkowitz, R., Eberlein-Vries. R.. & Sturgeon. D. (1982). A controlled trial of social
intervention in the families of schizophrenic patients. British Journal of Psychiatry. 141, 121-134.
Lesser. I .• Miller. B., Swartz. R.. Boone. K.. Mehringer. C., & Mena. I. (1993). Brain imaging in late-
life schizophrenia and related psychoses. Schizophrenia Bulletin. 19, 773-782.
Lewine. R. J. (1988). Gender in schizophrenia. In H. A. Nasrallah (Ed.). Handbook of Schizophrenia
(Vol. 3. pp. 379-397). Amsterdam: Elsevier.
Lewine. R. R. J. (1990). A discriminant validity study of negative symptoms with a special focus on
depression and antipsychotic medication. American Journal of Psychiatry. 147, 1463-1466.
Lewine. R. R. J.• Gulley. 1. R.. Risch. S. Coo Jewart. R.. & Houpt. J. 1. (1990). Sexual dimorphism.
brain morphology. and schizophrenia. Schizophrenia Bulletin, 16, 195-203.
Liberman. R. P.• Mueser. K. T.. & Wallace. C. J. (1986). Social skills training for schizophrenic indi-
viduals at risk for relapse. American Journal of Psychiatry, 143, 523-526.
Liberman. R. P.• Mueser. K. T.• Wallace. C. J.• Jacobs. H. E .• Eckman. T.. & Massel. H. K. (1986). Train-
ing skills in the psychiatrically disabled: Learning coping and competence. Schizophrenia
Bulletin, 12.631-647.
Liberman. R. P.• DeRisi. W. J.. & Mueser. K. T. (1989). Social skills training for psychiatric patients.
Needham Heights, MA: Allyn & Bacon.
Light. E.• & LebOWitz. B. D. (1991). The elderly with chronic mental illness. New York: Springer.
MacGregor. P. (1994). Grief: The unrecognized parental response to mental illness in a child. So-
cial Work. 39. 16D-166.
Marder. S. R.. Liberman. R. P., Wirshing. W. C.• Mintz. J.• Eckman. T. A .. & Johnston-Cronk. H. (in
press). Management of risk relapse in schizophrenia. American Journal of Psychiatry.
Meeks. S .• Carstensen. L. L.. Stafford. P. Boo Brenner. L. Loo Weathers. Foo Welch. R.. & Oltmanns.
T. F. (1990). Mental health needs of the chronically mentally ill elderly. Psychology and Ag-
ing. 5, 163-171.
Meltzer, H. Y. (1990). Clozapine: Mechanism of action in relation to its clinical advantages. In A.
Hales, C. N. Stefanis. & J. Talbott (Eds.). Recent advances in schizophrenia (pp. 237-256). New
York: Springer-Verlag.
Meltzer. H. Y. (1994). An overview of the mechanism of clozapine.Journal of Clinical Psychiatry. 55
(Suppl. B). 47-52.
Mittelman. M .. Ferris. S .• Shulman. E.• Stenberg. G.• Mackell. J.• & Ambinder. A. (1994). Efficacy of
a multicompont individualized treatment to improve the well-being of AD caregivers. In E.
Light. G. Niederehe. & Lebowitz (Eds.). Stress effects on family caregivers of Alzheimer's pa-
tients (pp. 185-204). New York: Springer.
Mittelman. M. S .• Ferris. S. H .• Shulman. E.• Steinberg. G. & Levin. B. (1996). A family intervention
to delay nursing home placement of patients with Alzheimer disease: A randomized con-
trolled trial. Journal of American Medical Association, 276 (21).1725-1731.
Moak. G. S. (1990). Discharge and retention of psychogeriatric long-stay patients in a state mental
hospital. Hospital and Community Psychiatry. 41.445-448.
Moak. G. s. (1996). When the seriously mentally ill patient grows old. In S. M. Sorreff (Ed.). Hand-
bookfor the treatment of the seriously mentally III (pp. 279-294). Seattle: Hogrefe & Huber.
Mueser. K. T.• & Glynn. S. M. (1995). Behavioral family therapy for psychiatric disorders. Needham
Heights. MA: Allyn & Bacon.
Schizophrenia 193
Mueser, K. T., Yarnold, P. R, Levinson, D. F., Singh, H., Bellack, A. S., Kee, H., Morrison, R 1., &
Yadalam, K. G. (1990). Prevalence of substance abuse in schizophrenia: Demographic and
clinical correlates. Schizophrenia Bulletin, 16,31-56.
Mueser, K. T., Douglas, M. S., Bellack, A. S., & Morrison, R 1. (1991). Assessment of enduring
deficit and negative symptom subtypes in schizophrenia. Schizophrenia Bulletin, 17,
565-582.
Mueser, K. T., Sayers, S. 1., Schooler, N. R, Mance, R M., & Haas, G. 1. (1994). A multi-site inves-
tigation of the reliability of the Scale for the Assessment of Negative Symptoms. American
Journal of Psychiatry, 151,1453-1462.
Mueser, K. T., Wallace, C. T., & Liberman, R P. (1995). New developments in social skills training.
Behavior Change, 12,31-40.
Mueser, K. T., Valentiner, D. P., & Agresta, T. (in press). Coping with negative symptoms of schizo-
phrenia: Patient and family perspectives. Schizophrenia Bulletin.
Mulsant, B. H., Stergiou, A., Keshavan, M. S., Sweet, R A., Rifai. A. Hoo Pasternak, Roo & Zubenko,
G. S. (1993). Schizophrenia in late life: Elderly patients admitted to an acute care psychiatric
hospital. Schizophrenia Bulletin, 19, 709-721.
Nuechterlein, K. H., & Dawson, M. K (1984). A heuristic vulnerability/stress model of schizo-
phrenic episodes. Schizophrenia Bulletin, 10, 300-312.
Pearlson, G. D., & Rabins, P. V. (1988). The late-onset psychoses-Possible risk factors. Psychiatric
Clinics of North America, Psychosis and Depression in the Elderly, 11, 15-33.
Pearlson, G. D., Kreger, 1., Rabins, P. V., Chase, G. A., Cohen, B., Wirth, J. B., Schlaepfer, T. B., &
Tune, 1. K (1989). A chart review study oflate-onset and early-onset schizophrenia. American
Journal of Psychiatry, 146, 1568-1574.
Pickar, D. (1995). Prospects for the pharmacotherapy of schizophrenia. Lancet. 4, 345 (8949),
557-562.
Platt, S. (1985). Measuring the burden of psychiatric illness on the family: An evaluation of some
rating scales. Psychological Medicine, 15,383-393.
Post, F. (1966). Persistent persecutory states of the elderly. London: Pergamon.
Prager, S., & Teste, D. V. (1993). Sensory impairment in late'-life schizophrenia. Schizophrenia Bul-
letin, 19, 755-772.
Rabins, P. V., Pauker, S., & Thomas, J. (1984). Can schizophrenia begin after age 44? Comprehensive
Randolph, K T., Eth, S., Glynn, S. M., Paz, G. G., Leong, G. B., Shaner, A. 1., Strachan, A., Van Vort,
W., Escobar, T. I., & Liberman, R P. (1994). Behavioral family management in schizophrenia:
Outcome of a clinic-based intervention. British Journal of Psychiatry, 164,501-506.
Roy, A. (1986). Suicide in schizophrenia. In A. Roy (Ed.), Suicide (pp. 97-112). Baltimore: Williams
& Wilkins.
Salokangas, R K. R, Palo-Oj a, T., & Ojanen, M. (1991). The need for social support among out-
patients suffering from functional psychosis. Psychological Medicine, 21, 209-217.
Salzman, C., Vaccaro, B., & Lief, J. (1995). Clozapine in older patients with psychosis and behavioral
disruption. American Journal of Geriatric Psychiatry, 3, 26-33.
Seeman, M. V. (1986). Current outcome in schizophrenia: Women vs. men. Acta Psychiatrica Scan-
dinavica, 73,609-617.
Seeman, M. v., & Lang, M. (1990). The role of estrogens in schizophrenia gender differences. Schiz-
ophrenia Bulletin, 16, 185-194.
Solomon, P., Draine, T., Mannion, E., & Meisel, M. (1996a). Impact ofbrieffamily psychoeducation
on self-efficacy. Schizophrenia Bulletin, 22, 41-50.
Solomon, P., Draine, T., Mannion, K, & Meisel, M. (1996b). The impact ofindividualized consulta-
tion and group workshop family psychoeducation interventions on ill relative outcomes. Jour-
nal of Nervous and Mental Disease, 184,252-255.
Stone, R, & Kemper, P. (1989). Spouses and children of disabled elders: How large a constituency
for long-term care reform? Milbank Quarterly. 67, 485-506.
Szymanski, S. R, Canoon, T. H., Gallacher, F., Erwin, R T., & Gur, R E. (1996). Course of treatment
response in first-episode and chronic schizophrenia. American Journal of Psychiatry, 153,
519-525.
Tarrier. N.• Barrowclough. C.• Vaughn. C.. Bamrah. J.. Porceddu. K. Watts. S .. & Freeman. H. (1988).
The community management of schizophrenia: A controlled trial of a behavioral intervention
with families to reduce relapse. British Journal of Psychiatry, 153,532-542.
Tarrier. N .. Beckett. R.. Harwood. S .. Baker. A.• Yusupoff. L.. & Ugarteburu. I. (1993). A trial of two
cognitive behavioral methods of treating drug-resistant residual psychotic symptoms in schiz-
ophrenic patients. I. Outcome. British Journal of Psychiatry, 162.524-532.
Taylor. A.• & Dowell. D. A. (1986). Social skills training in board and care homes. Psychosocial Re-
habilitation Bulletin. 10, 55-69.
Test. M. A.. & Berlin. S. B. (1981). Issues of special concern to chronically mentally ill women. Pro-
fessional Psychology, 12, 136-145.
Test. M. A.• Burke. S. S .. & Wallisch. 1. S. (1990). Gender differences of young adults with schizo-
phrenic disorders in community care. Schizophrenia Bulletin, 16, 331-344.
Tsuang. M.. & Winokur. G. (1975). The Iowa 500: Field work in a 35-year follow-up of depression.
mania and schizophrenia. Canadian Psychiatric Association Journal, 20, 359-365.
Tsuang, M. T., Woolson, R. F.• & Fleming. J. A. (1980). Premature deaths in schizophrenia and af-
fective disorders. Archives of General Psychiatry, 37, 979-983.
Van Putten, T., & Marder, S. R. (1986). Low-dose treatment strategies. Journal of Clinical Psychiatry,
47 Suppl. 5). 12-16.
Vaughn, C.• & Leff. J. (1976). The influence of family and social factors on the course of psychiatric
illness. British Journal of Psychiatry, 129, 125-137.
Vaughn, C., Snyder, K, Jones, S .• Freeman. W.. & Falloon. I. (1984). Family factors in schizophre-
nia relapse. Archives of General Psychiatry. 41.1169-1177.
Ventura. J.• Nuechterlein. K H .. Lukoff. D., & Hardesty, J. P. (1989). A prospective study of stressful
life events and schizophrenic relapse. Journal of Abnormal Psychology. 98,407-411.
Wing, J. H. (1987). Long term social adaptation in schizophrenia. In N. E. Miller & G. D. Cohen
(Eds.). Schizophrenia and aging (pp. 183-199). New York: Guilford.
Wright, 1., Clipp, E.. & George, 1. (1993). Health consequences of caregiver stress. Medicine. Exer-
cise, Nutrition, and Health, 2, 181-195.
Wyatt, R. J. (1991). Neuroleptics and the natural course of schizophrenia. Schizophrenia Bulletin,
17, 325-351.
Xiong. W.• Phillips. M. R.. Hu. X., Ruiwen, W., Dai, Q., Kleinman, J., & Kleinman, A. (1994). Fam-
ily-based intervention for schizophrenic patients in China: A randomised controlled trial.
British Journal of Psychiatry, 165,239-247.
Yassa, R, & Suranyl-Cadotte, B. (1993). Clinical characteristics of late-onset schizophrenia and
delusional disorder. Schizophrenia Bulletin, 19, 701-707.
Zigler, E., & Glick, M. (1986). A developmental approach to adult psychopathology. New York: Wiley.
Zisook, S., Heaton, R., Moranville, J., Kuck, J., Jernigan, T., & Braff, D. (1992). Past substance abuse
and clinical course of schizophrenia. American Journal of Psychiatry, 149,552-553.
CHAPTER 10
Depression
PATRICIA A. AREAN, HEATIlER UNCAPHER,
AND DEREK SATRE
INTRODUCTION
For many decades our society believed that to be old was to be depressed. To
some extent the myth is still pervasive that with old age comes problems with
health, finances, and loss of friends, family, and purpose. If one thinks this way,
one would certainly believe that the later years of life constitute a bleak time that
is hopeless and bereft of any joy. However, recent research has indicated that this
belief is not an accurate picture of later life. According to the McArthur Foun-
dation Successful Aging studies, the process of aging is variable; not everyone
who ages becomes disabled, dissatisfied with life, or depressed (Curb et al.,
1990). These findings are further corroborated by the results of the Epidemio-
logical Catchment Area Study, which demonstrated that Major Depression (one
of the most serious and widely studied of the mood disorders) is less prevalent
in people over the age of 65 than it is in younger age groups: 1 % of older adults
had a lifetime prevalence of Major Depression whereas 6% of younger adults
had a Major Depressive Episode in their lives (Robins et a1., 1984).
If depressive disorders are so uncommon in late life, then why bother
studying them? Even though only a small percentage of older adults will ever
become depressed, those few people who do become depressed are very dis-
abled by the symptoms of these disorders. For instance, research indicates that
older adults who have Major Depressive Disorder will die sooner from an ill-
ness than nondepressed older adults with the same physical illness. Older
adults with minor depression (one of the Depressive Disorders Not Otherwise
Specified (NOS) are more disabled, report more physical pain, and use more
health services than older adults without any depressive symptoms (Callahan,
PATRICIA A. AREAN AND DEREK SATRE • Department of Psychiatry, University of California-San Fran-
cisco, San Francisco, California 94143-0984 HEATIlER UNCAPHER, Department of Psychology, Univer-
sity of California-Berkeley, Berkeley, California, 94720.
195
196 Patricia A. Arelin et 01.
Hui, Nienaber, Musick, & Tierney. 1994; Ganzini, Lee, Heintz, Bloom, & Fenn,
1994). Moreover, senior citizens who attempt to take their lives are more suc-
cessful at completing a suicide than any other age group: nearly half of all sui-
cide attempts are completed. Depressive disorders in late life constitute a major
public health concern.
Depressive disorders (Major Depression. Dysthymia. and Depression
NOS) are among the most widely studied psychiatric phenomena in geri-
atrics, second only to Alzheimer disease and other dementias. In the past ten
years, substantial research has been carried out to understand the etiology.
prevalence. presentation. and treatment of depression in community-
dwelling older adults. However. considerable controversy remains as to the
etiology of late-life depression, how to assess and recognize depressive disor-
ders in older adults. and what interventions are most useful for treating de-
pression in late life. Further. the research into the course. cause. and
prevalence of these disorders in minorities. frail elderly, and other special
populations is still preliminary. The purpose of this chapter. then. is to review
the current research on late-life depression. discuss the controversies, and
discuss treatment outcome studies.
DEPRESSIVE DISORDERS DEFINED
Classification
The Diagnostic and Statistical Manual of Mental Disorders. 4th ed. (DSM-W;
American Psychiatric Association. 1994) classifies depressive disorders into
three groups: Major Depressive Disorder (MDD), Dysthymia. and Depressive Dis-
order NOS (DDN: includes Minor Depression. Depression due to Medical Con-
ditions or Substance Use). These disorders have overlapping symptoms and
presentations, but differ in their prevalence. course. and symptom severity. MDD
is the most serious of the three. DSM-JV describes an episode ofMDD as consist-
ing of feelings of depression and/or lack of interest in pleasant activities for two
weeks, every day, nearly all day. and five or more of the following symptoms:
appetite or weight disturbance. sleep disturbance. psychomotor retardation or
agitation, fatigue. difficulty concentrating, feelings of guilt or worthlessness,
thoughts of death or suicide. As stated earlier. only 1 % of older adults in com-
munity samples experienced an episode of MDD during their lifetimes (Regier
et a1., 1988). However. MDD appears to be quite prevalent in ambulatory medical
settings: 10% according to Koenig and Blazer (1992) and Arean and Miranda
(1995). As many as 12.3% of seniors in nursing homes suffer from MDD (P. A.
Parmalee, Katz, & Lawton. 1991).
Minor Depression (one of the DDN subgroups) is the most common disor-
der in late life, with as many as 30% of older adults having experienced an
episode during their lifetimes. regardless of setting (Arean & Miranda, 1995;
Parmalee. Katz. & Lawton, 1989). This disorder is similar to but less severe than
MDD, with only three of the depressive symptoms mentioned above present
nearly every day for at least two weeks.
Depression 197
Dysthymia is a mild, yet more chronic depressive disorder, in which the

above-mentioned symptoms of depression exist for two years or more but are
experienced on occasion throughout a week. Dysthymia is also more preva-
lent than MDD, but less so than Minor Depression, with only 10% of the el-
derly population having experienced an episode during their lifetimes (Regier
et a1., 1988). Rates of this disorder in medical and skilled nursing settings is
unknown.
Late Versus Early Onset
Although DSM-W does not include a special classification for geriatric de-
pression, there is speculation that depressive disorders that first occur after the
age of 65 are different from disorders with an earlier onset in terms of their eti-
ology and presentation. Gerontologists refer to this phenomenon as late-life, or
geriatric, depression (Blazer, 1990; Devanand et a1., 1994). Research differenti-
ating late- and early-onset depressions is preliminary. However, we do know
that people with geriatric depression present with more extreme weight loss,
hypochondriacal preoccupation, trouble falling asleep, agitation, and preoccu-
pation with guilt (Brown et a1., 1984). Moreover, differences between geriatric
depression and early-onset depressions indicate that older adults who have had
a previous episode of depression were more likely to have a personality disor-
der than were older adults with geriatric depression (Devanand et a1., 1994).
People with geriatric depression are less likely to suffer another depressive
episode, but geriatric depressives who do relapse show symptoms within 2
months of treatment. Older adults with early-onset depression tend to relapse
within 6 months (Baldwin & Jolley, 1986).
ETIOLOGY
Many geriatricians believe that late-life depressive disorders result from

chronic life stressors, genetic, biological, and endocrinological factors, and
physical illnesses. In older adults, the main risk factors for depression are a pre-
vious history of depression, current physical illness, recent stressful life events,
social and economic deprivation, and living alone (Henderson, 1989). The
course and prognosis of depressive disorders vary. Some studies show that
older adults have poorer treatment outcomes and higher rates of relapse than
younger people (Alexopoulos, Young, Meyers, Abrams, & Shamolan, 1988),
whereas more recent research suggests that course and prognosis of MDD in
older adults is similar to that of younger adults. According to Brodarty and col-
leagues (1993), people with geriatric depression tend to show greater improve-
ments over time, respond better to .treatments for depression than younger
patients, and are less likely to relapse than younger adults or older adults with
an early-onset depression. These findings are preliminary, and more prospec-
tive and longitudinal research is needed to understand the course of geriatric
depression and depressive disorders in older adults.
198 Patricia A. Arean et al.
Psychosocial Factors in Depression in Older Adults
Older adults often identify a stressful life event as the precursor to their de-
pressive episode. The most common stressful life events are physical disability,
financial stress, caring for a chronically ill family member, and grief over the
loss of a social role or important family member (Markides & Cooper, 1989).
However, many older adults faced with these problems do not become de-
pressed. Theorists suggest that amount of preparation and social support one
has in dealing with a stressful life event may determine whether a senior citizen
will become depressed. For instance, loss of a loved one or retirement do not af-
fect the well-being of older adults as much as they do younger adults, who may
be less prepared for such types of stressors (George, 1989). Senior citizens who
plan ahead for retirement or illness are less likely to suffer psychologically than
those who do not prepare.
Some studies indicate that depressed seniors are more likely to be socially
isolated and have fewer social outlets than older adults who are not depressed.
In addition, perceived social support (whether older adults feel they have peo-
ple they can turn to) mediates the impact of a stressful life event on depressive
symptoms (Husiani et aI., 1991). Krause (1987) found that depressed seniors
had less emotional support for their problems and fewer social contacts than se-
niors who were not depressed. Although the causal direction of the relationship
between social support and late-life depression is not known, it is likely that
those older adults who are at greatest risk for becoming depressed are those
who feel they have no one to turn to in times of stress.
In addition to stressful life events and few social supports, many depressed
older adults tend to have limited problem-solving skills. Only a few studies
have investigated the role coping skills play in depression in older adults, but
preliminary evidence suggests that senior citizens who are active problem
solvers (assertively pursuing information about a problem and then developing
a plan to solve it) are less likely to be depressed than seniors with more passive
and unassertive coping styles (Fry, 1989; Thompson & Gallagher-Thompson,
1993). Moreover. seniors who are religious or cope better with uncontrollable
events, such as a chronic medical illness, are also less likely to be depressed
than those older adults who are not religious (Koenig et aJ., 1989).
Late-life depression has also been found to be associated with both social
and biological changes. From a psychosocial perspective, geriatric depression
is due to the inability to cope with life problems specific to aging. Older adults
have never had to face many of the medical and financial problems that can oc-
cur in late life, and therefore are unprepared for and ill equipped to deal with
these events (Are an & Miranda, 1997). Repeated exposure to the inability to
solve problems then results in learned helplessness reactions, which subse-
quently lead to depression (Yost et a1., 1986).
In summary, older adults are more likely to become depressed if they are
faced with stressors for which they are unprepared, have few social supports,
and are relatively passive problem solvers. Therefore, older adults most vul-
nerable to depressive disorder are those who are more isolated socially and en-
counter stressful situations with which they are unable to deal. Therapies
Depression 199
aimed at increasing social supports and coping abilities would be beneficial in

treating depression in the elderly.
Biology and Neuroendocrinology
There has been much research investigating the biology of late-life depres-
sion, particularly geriatric onset depressions. Such research suggests that bio-
logical variables responsible for onset of a depressive episode in late life
include severe lesions in the frontal deep white matter and basal ganglia of the
brain (Krishnan, 1991), dysregulation of endocrine function (specifically. in-
creased cortisol levels; D. Blazer, 1990), and a dearth of cerebral neurotransmit-
ters such as serotonin. The most compelling of these arguments is the role of
cortisol in the development of depression. High levels of cortisol have been
consistently related to physical illness, stress, and depression (Blazer, 1990).
Cortisol levels increase with age, as does dysregulation of the endocrine system.
This may make older adults vulnerable to depression (Blazer, 1990). However,
because depression is a relatively rare disorder in older adults, the cortisol hy-
pothesis does not explain all depression, but this hypothesis may explain why
physically ill elderly (who have even more increased cortisol) are more likely to
be depressed.
The neurotransmitter hypothesis indicates that depression in older adults
may be due to, or correlated with, a depletion of essential neurotransmitters in
the brain. For years a lack of neurotransmitters norepinephrine and serotonin
has been associated with depression. It is not clear whether lack of these chem-
icals is the cause or consequence of developing a depressive disorder, but they
do seem to play an important role.
From a biological perspective, there is evidence to suggest that people
with late-onset depression are more likely to have cerebral changes and in-
juries than older adults who are not depressed. For instance. researchers have
found that those with geriatric depression have a higher incidence of cerebral
vascular disease, significant delays in the auditory evoked response. and
anatomic changes such as ventricular dilation and cortical atrophy (Alex-
opoulos et 01., 1988). There is also evidence to demonstrate that people with
geriatric depression are more likely to develop subsequent dementing illness.
Most researchers are still uncertain as to the significance of these correla-
tions, but most believe that there is a biological component to late-onset de-
pression.
Physical Illness
Depression is highly prevalent in patients of all ages with acute and

chronic medical illness. Older adults are particularly susceptible because they
are more likely to be sick than younger adults. In older adults with cardiac, pul-
monary, endocrine, and neurological disorders, functional disability, and can-
cer, high prevalence rates of depression are reported (Dreyfus, 1988).
200 Patricia A. Arean et al.
Many possible causes of depression in ill people have been identified. Sub-
stances (e.g., drug, alcohol, lead) and medications (e.g., antihypertensives, dig-
italis, benzodiazepines, analgesics, I-dopa, antimicrobial agents, cardiovascular
agents, hypoglycemic agents, and steroids) can produce depressive symptoms
because of the physiological changes these disorders create. Medical condi-
tions, diseases, and physiologic disturbances can also cause depressive symp-
toms through brain tissue damage. For instance, cerebrovascular accidents
(stroke), seizure disorders, dementia (e.g., Alzheimer's disease), postconcussive
syndrome, normal pressure hydrocephalus, and cerebral hypoxia have all been
identified as contributing to depression in some older patients. Poststroke de-
pressions are particularly prevalent up to two years after a cerebral incident
(Robinson & Price, 1982). In addition, coronary artery disease and chronic ob-
structive pulmonary disorder are two medical conditions in which depression
may significantly predict disability (Weaver & Narsavage, 1992).
Cancer and diabetes are also associated with depression. The prevalence of
depression in cancer patients has been estimated to be from 4.5% to 58% (Massie,
Gagnon, & Holland, 1994). Other diseases, such as Alzheimer's and Parkinson's
disease, infectious diseases (e.g., AIDS, encephalitis. meningitis, syphilis. hep-
atitis), and autoimmune diseases or inflammatory conditions (e.g., arthritis,
pancreatitis, multiple sclerosis, and systemic lupus erythematosus) are accom-
panied by high rates of depression and are thought to playa role in the onset of
depression in older adults (Evans, Copeland, & Dewey, 1991). Many ofthese dis-
eases create physiological changes resulting in depressive disorder, but they also
create psychosocial difficulties, such as financial drain, disability, and pain.
Gerontologists believe that physical illness impacts depressive symptoms di-
rectly through physiological change and indirectly through psychological stress.
Comments
Depression in older adults appears to be a function of several factors. Research

suggests that older adults who are sick, are stressed financially and socially, who
have few social supports, poor coping skills, and are biologically vulnerable are
more likely to become depressed. Age of onset also appears to be important. and
early evidence suggests that late-onset depression may have a strong biological
component. The field of geriatrics would benefit from studies examining the rela-
tive impact that all these factors play in depressive disorders in senior citizens so
that treatment decisions and preventive measures can be implemented.
ASSESSMENT OF DEPRESSION IN
THE ELDERLY
Overview
Depression in late life is not easy to diagnose, largely because 75% of

older adults have at least one chronic medical illness that may mimic or share
symptoms of depressive disorders (G. Klerman, 1989). For many years, gero-
Depression 201
psychologists have struggled over the best way to recognize these disorders
in older populations. In order to appreciate the difficulty in recognizing late-
life depression, one should be familiar with the criteria for making a diagnosis
ofMDD.
Many reports describe difficulties in establishing a concise symptom pro-
file of depression in the elderly. Certain vegetative symptoms that contribute to
a diagnosis of depression, (e.g., insomnia, early morning awakening, and de-
creased appetite), are likely to be present in nondepressed as well as depressed
older adults. In addition, although depressed older adults may present with ap-
athy, fatigue, weight loss, sleep disturbance. and lack of initiative (Achte, 1988),
older adults with poor physical health might present with the same symptoms,
and not be depressed (Neese, 1991). Older adults vary widely in their func-
tional capacity, social support, cognitive functioning, activity, sleep, and ap-
petite. Thus an important aspect of diagnosis is to determine whether the
constellation of symptoms is impairing the older adult's normal baseline func-
tioning. Patients are asked whether any of these potential symptoms are recent
changes and whether these changes have resulted in an impairment of usual
functioning.
Researchers and clinicians disagree on how to consider physical symptoms
in the diagnosis of depression. Some clinicians and researchers emphasize that
physical symptoms or illness and depression occur together so often that they
should be evaluated together (Caine, Lyness, King, & Conners, 1991). Some sug-
gest that physical symptoms might be indicative of depression in older adults.
For example, sleep disturbance (Gallo, Anthony, & Muthen, 1994), appetite dis-
turbance, and weight loss appear to be more prevalent in older versus younger
patients with Major Depressive Disorder (Blazer, Bachar, & Hughes, 1987) and
may be important signs of depression in late life.
Variations in definition of depression are reflected in various standard-
ized interviews and diagnostic categories. The DSM-IV, ICD-l0 and the Diag-
nostic Interview Schedule (DIS) (Robins, Helzer, Croughan, & Ratcliff. 1981)
all exclude symptoms of depression from a diagnosis of Major Depressive
Disorder if they are considered to be due to a physical illness or condition.
Exclusion of these symptoms may have clinical and research implications.
For example, excluding physical symptoms from a diagnosis of depression
may result in underestimation of depression in physically ill older adults
(Newmann, 1989). These considerations all need to be taken into account
when conducting an unstructured interview to diagnose depression in older
adults.
Debate continues as to the constellation of symptoms that characterize geri-
atric depression in an unstructured interview. Depression might be qualita-
tively different in the elderly and involve symptoms not considered standard
diagnostic criteria, such as helplessness (Depue & Monroe, 1978), hopelessness
(Abramson, Metalsky, & Alloy, 1989). real or perceived cognitive deficit (Weiss,
Nagel, & Aronson, 1986), or anxiety. Some investigators suggest that dysphoric
mood may be a less salient feature in some older adults (Arean & Miranda,
1992; Gallo et al., 1994). Others have reported that older patients with depres-
sion endorsed dysphoric mood (Koenig et al., 1992), so the issue remains con-
troversial and in need of clarification.
202 Patricia A. Arean et a1.
Methods of Assessment
Because of difficulties surrounding diagnosis of depression in older adults

with an unstructured interview, gerontologists often rely on standardized in-
struments to help clarify a diagnosis of depressive disorder. There is a variety of
methods for assessing depression in late life, including self-report scales and
structured interviews.
Self-report scales are questionnaires that can either be read to or by the pa-
tient to determine the severity of depressive symptoms. Answers to specific
questions are added to determine an overall depression score. These instru-
ments are meant to be sensitive enough to identify everyone who is depressed.
The Geriatric Depression Scale (GDS; Brink et a1., 1982), and the Zung Self-Rat-
ing Depression Scale (SRS; Zung, 1965) have been created specifically for
adults. The GDS is a 3D-item scale that asks about symptoms of depression in a
True/False format. The Zung is a 20-item scale in which each item has a four-
choice format ranging from "none of the time" to "all of the time." Both of these
scales have excellent reliability and validity and they are equally useful in de-
tecting depression in older adults (Hickie & Snowdon, 1987). However, one
study compared the GDS to the SRS and found that although they were equally
effective in identifying depression in older adults, the GDS was the easiest scale
for the older subjects to complete (Dunn & Sacco, 1989). The GDS. therefore,
may be preferable because of its simple response format.
Other self-report measures, such as the Beck Depression Inventory (BDI;
Beck et a1., 1961), and the Center for Epidemiological Studies-Depression
Scale (CES-D; Radloff, 1977) also appear to have sound psychometric properties
for detecting depression in the elderly. However. given that such studies are
sparse, it may be prudent to rely on scales developed exclusively for the geri-
atric population.
The main drawback of self-report measures for detecting depression is their
tendency to overestimate presence of MDD in older adults. For research pur-
poses, several structured clinical interviews exist that provide a strict guideline
and list of questions for clinicians to adhere to when conducting a diagnostic
interview. Included in these interviews are The Structured Clinical Interview
for DSM-IV (SCID; First et a1., 1994), the Schedule for Affective Disorders and
Schizophrenia (SADS; Spitzer et a1., 1988), and the Diagnostic Interview Sched-
ule (DIS; Robins, 1981). All of these interviews follow a similar format. The
questions are structured around the Diagnostic and Statistical Manual of Men-
tal Disorders, 3rd ed., rev. (DSM-III-R; American Psychiatric Association, 1987)
or DSM-W criteria for diagnosing depressive disorders, are meant to be admin-
istered by trained clinicians, and provide an objective means of determining a
diagnosis. Dolores Gallagher-Thompson reviewed six of these structured in-
terviews: the SADS, the DIS, the Comprehensive Assessment and Referral
Evaluation (CARE) (Gurland et a1., 1983), the Older Americans Resources and
Services (OARS) Multidimensional Functional Assessment Questionnaire
(MFAQ) (Duke University Center for the Study of Aging, 1978), the Longitudi-
nal Interval Follow-up Evaluation (LIFE) (Shapiro & Keller, 1979), and the
Hamilton Rating Scale for Depression (HRS-D) (Hamilton, 1960). The SADS was
the most reliable and valid diagnosis of depression in community older adults
(Gallagher, 1986).
Depression 203
Comment
Assessing depression in older adults is complex. We know that older adults

may present or emphasize different depressive symptoms from younger pa-
tients. For instance, older depressed adults seem to be more hopeless, anxious,
dysphoric, and have more somatic changes, such as sleep and appetite distur-
bance. Somatic symptoms need to be evaluated carefully so that the normal
process of aging is not confused with depression. Additionally, a physical ex-
amination should always be conducted to determine whether there is a physio-
logical cause. As a final note, the importance of assessing for suicidal ideation
in this population is underscored by the relatively high successful suicide rate
in older adults. It is imperative that clinicians ask their older patients directly
about potential suicidal feelings and plans. Asking about suicide will not put
the idea in an older person's mind.
TREATMENT OF GERIATRIC DEPRESSION
Despite difficulties in diagnosing depression in late life, MDD is easily

treated in older adults. Pharmacotherapy, electroconvulsive therapy, and psy-
chotherapeutic approaches have all been successful in treating depression in
senior citizens.
The Use of Psychotherapy for Geriatric Depression
Psychosocial treatments used with older adults include cognitive, behav-

ioral, psychodynamic, reminiscence, and interpersonal therapy. Many clinical
reports have been published over the past 40 years demonstrating efficacy of
psychological interventions for older adults (Smyer, Zarit, & Qualls, 1990;
Weiss & Lazarus, 1993). Based on a review ofthe treatment literature, the No-
vember 1991 National Institutes of Health (NIH, 1992) Consensus Development
Conference on Diagnosis and Treatment of Depression in Late Life (Washington,
DC) recommended that psychotherapy be used after a trial of pharmacotherapy
and electroconvulsive therapy. The panel indicated that this recommendation
was based on the lack of studies investigating the efficacy of psychotherapy in
older adults. There are now several studies of note that indicate the efficacy of
psychotherapy in late-life depression. One metanalysis identified 17 articles ex-
amining the efficacy of psychosocial interventions for treating depression in
older adults (Scogin & McElreath, 1994). The results suggest that psychosocial
interventions are highly effective for treating both geriatric major depression
and minor levels of depression.
Conducting Therapy With an Older Person
In all types of therapy with the older adult, the therapist should educate the
person about therapy, keep the pace slower, and attempt to prevent relapse and
recurrence through booster sessions (Gallagher-Thompson & Thompson, 1992).
204 Patricia A. Arean et 01.
Some geriatricians will often help patients remember the elements of their ther-
apy by providing the older client with a journal and written materials, and
sometimes reminder calls are given during the week to provide the older adult
with additional support around completing out-of-session assignments. A ther-
apist should also keep in mind that not all older people have the same devel-
opmental experiences. An octogenarian is 20 years older than a person who is
60,-and clearly grew up with different experiences and values. Therapists must
remain flexible and educate themselves about their older patients' develop-
mental experiences.
Cognitive-Behavioral Psychotherapy:
Theory and Process. One of the more empirically validated forms of ther-
apy with older adults is cognitive-behavioral psychotherapy (see Teri, Curtis,
Gallagher-Thompson, & Thompson, 1994, for review), a combination of cogni-
tive models (Beck, Rush, Shaw, & Emery, 1979), and behavioral models of psy-
chopathology (Lewinsohn, Biglan, & Zeiss, 1976). The cognitive-behavioral
model takes into account how a person's cognitive, affective, and behavioral re-
sponses to life events contribute to the development of depression. Specifically,
depression is due to the interaction of stress. coping abilities, problem-solving
skills, people's belief about whether they can cope with their problems. and
how supportive the world is around them. Issues from childhood or the past are
discussed only as to how they apply to problems occurring now. The goal of
therapy is to teach new coping strategies and to identify and challenge cogni-
tions that interfere with effective coping. This is achieved through collaborative
discussion of life problems, generating strategies to solve or cope with the prob-
lems. and implementing new strategies during the time between therapy ses-
sions, so that new skills can be practiced and reinforced.
Outcome Studies. Several studies have demonstrated the utility of CBT

in treating late-life depression (Arean et a1., 1993; Beutler et a1., 1987). CBT has
been compared to interpersonal therapy. finding positive change in depression
in all conditions, with the patients in the cognitive or behavioral conditions
scoring better on outcome depression scales 1 year later (Gallagher & Thomp-
son, 1982; Thompson, Gallagher, & Breckenridge. 1987). CBT has also been
compared with pharmacotherapy (Desipramine) alone and combined with CBT,
indicating that medication combined with therapy was more effective than cog-
nitive therapy alone, and that cognitive therapy alone was more effective than
medication alone (Thompson & Gallagher-Thompson, 1993).
Interpersonal Psychotherapy
Theory and Process. Interpersonal psychotherapy (ITP) (G. 1. Klerman,
Weissman, Rounsaville et a1., 1984) combines aspects of psychodynamic and
cognitive psychotherapy to focus on the patient's social roles and relationships
in the production, exacerbation, and maintenance of depression. ITP was de-
signed to address four specific areas: guilt, interpersonal disputes, role transi-
tions, and interpersonal deficits. The depressed older adult may experience
Depression 205
abnormal grief reactions, role transitions, and social problems that are ad-
dressed by this form of treatment. Variations of IPT treatment were developed
for older adults: interpersonal psychotherapy for late-life depression (IPT-LL)
and interpersonal psychotherapy for the maintenance treatment of recurrent de-
pression in late life (IPT-LLM) (Frank et 01., 1993). Included in these variations
are age-specific adaptations: a more flexible session, a more active role for the
therapist including problem solving and coping with disagreements. In the in-
terpersonal form of therapy, treatment begins with identifying important rela-
tionships in the patient's life. Problem areas and the nature of the identified
relationships and their contributions to depression are explored. Eight general
techniques assist this process, including the use of therapeutic relationship, ex-
ploratory and directive techniques, encouragement of affect, analyzing commu-
nication patterns, clarification. and behavior change techniques.
Outcome Studies. Preliminary positive findings ofIPT use with clients in

midlife and those aged 50 to 65 were reported (Schneider et 01., 1986). In eval-
uations on midlife adults, IPT-M was not found to enhance imipramine treat-
ment, but it was significant alone or with placebo compared to a placebo and
medical clinic visits (Frank et ai., 1993). More studies are needed to evaluate
the effectiveness of IPT for older adults. Treatment studies comparing IPT with
other forms of psychotherapy will enhance future evaluations.
Psychodynamic Psychotherapy.
Theory and Process. Psychodynamic psychotherapy originated with the
work of Freud and his emphasis on intrapsychic processes. At first not recom-
mended for older adults because of a number of assumptions, including rigid-
ity of character and defenses (Freud, 1959), psychodynamic psychotherapy is
now considered a viable form of treatment with older adults (Myers, 1991).
Given that the older patient has a willingness and ability to work with uncon-
scious issues, an ability to connect with the therapist. and a motivation to
change. psychodynamic therapies explore themes of object relatedness, uncon-
scious drives, self-esteem, self-worth, and resulting behaviors and relationships
(Myers, 1991). There are no variations of this form of therapy specifically for
older adults.
Outcome Studies. Individual psychodynamic psychotherapy is effective

in older adults (Altshuler, 1989). L. W. Lazarus and colleagues (1984, 1987)
studied the effectiveness of individual psychodynamic psychotherapy for de-
pressed older adults, and found lower distress, lower depression and defenses,
and increased self-esteem following treatment. However, very few empirical
studies exist.
Reminiscence Psychotherapy
Theory and Process. According to Eric Erikson (1959), throughout life
people are continually faced with syntonic and dystonic conflicts that create a
process of psychopathology until balance is reached between these conflicts
206 Patricia A. Arean et a1.
(Disch, 1988). In older adults, this struggle is between integrity (coming to terms
with coming to the end of life) and despair over past and present successes and
failures. This despair can often result in depression, and only through life re-
view and acceptance can depression be treated. To support this theory, several
studies have demonstrated that older adults who are depressed tend to engage
in less active reminiscing (or life review) than do those who are not depressed
(Blum & Tross, 1988). According to Lewis and Butler (1974), the most effective
type ofreminiscing takes place when memories are used to (1) reframe past ex-
perience, (2) achieve resolution, (3) resolve regrets about unattained goals, (4)
accept death and refocus on living, and (5) instruct the next generation. Ratten-
berg and Stones (1989) have found that the best way to treat depression through
this process is in a group setting, so that reminiscences of one person can stim-
ulate those of another.
Reminiscence therapy can take many forms, but the usual structure of this
therapy is to stimulate life review by discussing milestones in one's life and the
meaning those events have for the person. Discussion can be stimulated by pro-
viding prepared topics and bringing photographs and music from the older per-
son's generation. Discussion and reminiscence are guided to reflect upon these
events and then to work toward reframing the events, accepting them, and find-
ing ways for such experiences to be instructional.
Outcome Studies. In one of the few empirical studies, Haight (1992) com-
pared individual life review with supportive and no treatment conditions in a
sample of 52 older adults, and reported increased life satisfaction and de-
creased depressive symptoms. Reviewed often and very popular in geriatric set-
tings, RT appears to be most suitable for healthy adults. Although efficacy of
reminiscence therapy is supported by a few studies (e.g. Arean et aJ., 1993),
more empirical research is needed.
Comment
Overall, clinical and empirical evidence suggests that depressed elderly
have positive responses to the four main types of psychotherapy discussed
here. Similar to studies of young adults, studies of older adults to date have not
demonstrated empirical evidence for differences in treatment effects among the
four main approaches. All four are effective in reducing symptoms of depres-
sion in older adults.
Biological Interventions
The defining feature of biological interventions is to alter brain functioning

in depressed older adults. This is achieved by changing the neurochemistry of
the brain through inducing a shock (electroconvulsive therapy; ECT) or through
inducing higher levels of neurotransmitters in the brain (antidepressant med-
ication). Because these interventions produce a direct biological change, they
pose risks that should always be considered before using them. Below we re-
view the action, utility, and risks of these interventions.
Depression 207
Electroconvulsive Therapy (EeT)

Action and Indications. ECT remains a controversial treatment for de-
pression, although it is often described in the research literature as safe and ef-
fective for older adults (Burke, Zubin, Zorumski, & Wetzel, 1987; Kramer, 1987;
Rubin, Kinscherf, Figiel, & Zorumski, 1993). ECT involves the passing of an
electrical current through the brain, either bilaterally or unilaterally, inducing a
generalized seizure and unconsciousness in the patient. Although not well un-
derstood, induction of the seizure, rather than the electricity itself, may result
in therapeutic benefits, relieving symptoms of depression.
ECT may be employed as a last resort with severely depressed patients who
have not responded to antidepressant medications or for whom such medica-
tions are contraindicated. Other possible indications for ECT include refusal to
eat or drink and high suicide risk (Karlinsky & Schulman, 1984). For elderly pa-
tients who fall into these categories, ECT may be the only feasible treatment.
Outcome Studies. Whereas some investigators have concluded that ECT

is even more effective in the elderly than in younger patients (Weiner, 1992),
others have found no correlation between age and response rates (Karlinsky &
Schulman, 1984). Most studies of ECT with the elderly show significant de-
creases in depressive symptoms. In one study, 63.3% of depressed elderly pa-
tients who had not previously responded to antidepressant medications
showed significant improvement on symptoms of depression. Yet, this same
study also found very high rates of relapse, with 28% of patients treated with
ECT rehospitalized for depression within one year (Stoudemire et aJ., 1991).
Risks and Contraindications. The risk of cardiovascular complications

needs to be carefully investigated in elderly patients being considered for treat-
ment with ECT, since heart failure is the principal ECT-related medical compli-
cation and the most frequent cause of death during treatment. Patients taking
cardiovascular medications appear to be at higher risk for complications during
ECT (Burke et aJ., 1987). Two recent studies suggest that careful monitoring of
patients during and after treatment can minimize this risk even in patients with
severe cardiovascular disease (Rice, Sombrotto, Markowitz, & Leon, 1994). But
such additional monitoring may add to the already considerable expense and
hospitalization requirements of ECT. Rice and her associates concede that "low-
ering the risk for patients with cardiac impairment who receive ECT may be
possible only in settings with highly specialized medical services" (1994). ECT
has also been associated with increased risk of falling in the elderly (Burke et
aJ., 1987).
Perhaps the most serious drawback to the use of ECT is the risk of perma-
nent memory loss. Few studies have adequately addressed the extent of this
and other cognitive side effects in the elderly, although the risk of cognitive dys-
function may be greater than in younger patients (American Psychiatric Asso-
ciation, 1990). The higher doses of electricity necessary to induce seizures in
the elderly may be a factor in this increased danger. Some researchers have sug-
gested that the risk of memory loss and confusion in elderly patients receiving
ECT may be reduced by using brief pulse wave forms rather than sine wave
forms (Kramer. 1987). However. further study of the extent and nature of these
serious side effects in the elderly is necessary.
Comment. ECT remains a treatment of last resort. due to the risk factors
just described. its expense and hospitalization requirements. and the invasive
nature of the procedure. Although many studies demonstrate effectiveness of
ECT in the short term. the high rate of relapse is disturbing. Investigation of
long-term effectiveness and possible types of maintenance treatments following
ECT in elderly people remains to be done. Studies of the efficacy and side ef-
fects of ECT in those of very advanced age (over 80) have also yet to be con-
ducted.
Pharmacotherapy
Of all the options for the treatment of depressed elders. use of antidepres-
sant medications has been the most thoroughly researched. Because many of
these studies have demonstrated usefulness of these medications. they should
be considered when evaluating treatment options for depressed elderly indi-
viduals. There are currently three major categories of these drugs: tricyclics
(TCAs), monoamine oxidase inhibitors (MAOIs). and serotonin enhancers
(SSRIs). All of these drugs have shown some usefulness in clinical trials. and
there are also concerns common to all of them. In particular. side effects of these
medications are frequent and sometimes severe (Dunner. 1994). Preexisting
medical conditions may also interfere with successful treatment with anti-
depressants. causing intolerable side effects particularly in severely ill medical
patients (Koenig et aI., 1989).
When prescribing medications to older patients. clinicians must be careful
to avoid adverse interactions with other drugs that patients are already taking.
Because the elderly are more likely than younger people to be taking multiple
medications. risk of adverse interactions is increased. Another general concern
in prescribing antidepressant medications is greater compliance problems in
the elderly. Presence of cognitive impairment may increase the risk of adverse
effects. particularly if patients are not able to remember specific prescription re-
quirements.
Another consideration in prescription decisions is patient age. Descrip-
tions of successful research findings for use of antidepressants in the elderly are
not necessarily generalizable to patients of very advanced age. A recent review
of 400 reported controlled trials or case studies of antidepressant treatment in
the elderly found that while pharmacotherapy has been examined in more than
5000 individuals over 55 years old. only 45 subjects aged 80 and older have
been included in these trials (Salzman. 1994). Clinicians clearly should moni-
tor dosages and side effects in these oldest individuals with additional care if
treatment with antidepressants is decided.
In all elderly patients. initial dosage and increases in psychoactive med-
ication should be small. Patients should be carefully monitored for worsening
of symptoms and for potential side effects. Phamacokinetic effects of antide-
pressants may differ in elderly persons as compared with younger people: re-
Depression 209
duced rates of absorption, metabolism, and excretion lead to longer drug half-
lives (the time it takes for the amount of medication in the blood plasma to be
reduced by half). Because the drug stays in the older patient's body longer, there
is a prolonged risk of side effects. As a result, doses should begin at approxi-
mately one half to one third of that normally prescribed for younger patients
(Volz & Moller, 1994).
'fricyclics
Action and Indications. Tricyclic antidepressants (TCAs) block the presyn-
aptic terminals' reuptake of the neurotransmitters norepinephrine and serotonin.
The most frequently prescribed tricyclics include nortriptyline, amitriptyline, de-
sipramine, imipramine, doxepin, and maprotiline. Desipramine may be the most
appropriate of this group for depressed elders not experiencing anergia and anhe-
donia. Nortriptyline may be preferred for patients requiring more sedation or who
are especially sensitive to a decline in blood pressure (Salzman, 1994).
Outcome Studies. Studies investigating effectiveness of treating elderly

patients with TCAs frequently report good immediate response rates, coupled
with high levels of side effects. Cohn and colleagues (1990) found that
amitriptyline alleviated depressive symptoms in 62.5% of subjects as measured
by the Hamilton Rating Scale for Depression (HRSD), but 35 % of the subjects
withdrew from the study because of side effects.
Common side effects in Cohn's study for subjects receiving amitriptyline
included dry mouth (71.3%), dizziness (37.5%), constipation (27.5%), and fa-
tigue (22.5%). Similar levels of these side effects in the elderly have also been
reported for doxepin, such that only 39% of subjects receiving it completed the
trial (Feighner & Cohn, 1985). There is some evidence that nortriptyline may
cause fewer side effects in elderly patients than other TCAs (McCue, 1992). One
study showed a 62% response rate, with only 4% of subjects dropping out due
to side effects (Georgotas et aI., 1987).
Risks and Contraindications. Cardiac complications are a potentially se-

rious risk in treating elderly patients with TCAs. Possible problems include in-
creased heart rate, orthostatic hypotension, and arrhythmia (Glassman & Roose,
1994). These reactions have been correlated with high plasma levels of tri-
cyclics (Preskorn, 1993). As a result, use of tricyclics in the elderly may involve
serious risk (Goldman, Alexander, & Luchins, 1986). High plasma levels may
also lead to central nervous system toxicity, including delirium and seizures.
Elderly patients can develop these side effects at lower plasma levels than
would be required in younger patients (Preskorn, 1993).
Tricyclics may also lead to adverse reactions caused by pharmacodynamic
interaction with sedatives, including alcohol and antihistaminic agents often
found in nonprescription medication (Preskorn, 1993). They may also lead to
increased risk of falling, particularly among elderly women (Ruthazer & Lipsitz,
1993). Finally, tricyclics are highly toxic in overdose (Rickels & Schweizer,
1993), and should not be prescribed in situations of high suicide risk or if there
is a possibility of accidental overdose.
210 Patricia A. Arean et oJ.
Monoamine Oxidase Inhibitors (MAOIs)

Action and Indications. The oldest of the antidepressants. MAOIs in-
crease synaptic concentrations of norepinephrine. serotonin. and dopamine by
blocking oxidative enzymes in synaptic terminals. Commonly used MAOIs in-
clude phenylzine. tranylcypromine. and isocarboxazid. MAOIs are often used
for elderly patients who are mildly to moderately depressed and whose symp-
toms include extreme anergia. fatigue. and anxiety (Salzman. 1992). They also
may be useful for patients who are not eating enough or who are having trou-
ble sleeping.
MAOIs may be the best pharmacological treatment for atypical depression.
which is associated with increased appetite. weight gain. hypersomnia. anxiety.
neurotic symptoms, and hysteroid dysphoria. Symptoms of atypical depression
may worsen in the evening for patients who have trouble sleeping (Mendels,
1993).
Outcome Studies. There have been few controlled studies of MAO Is in el-
derly populations. In one study by R. Lazarus (1986), which tested only 15 sub-
jects, 47% of patients receiving phenylzine had an improvement of 25% or
better on the HRSD. Orthostatic hypotension was a common side effect. An-
other study by Georgotas. McCue. Friedman, & Cooper (1987) found that 61.1 %
of subjects receiving phenylzine had scores reduced from 16 or higher to 10 or
lower on the HRSD.
Risks and Contraindications. Orthostatic hypotension and low blood pres-

sure are common side effects of MAOIs (Goldman. 1986; Preskorn, 1993). An-
other concern is the pharmacodynamic interaction with serotonin-active agents
and foods containing high levels oftyramine. such as cheese (Preskorn. 1993).
Selective Serotonin Reuptake Inhibitors (SSRls)

Action and Indications. SSRIs are the newest of the three major categories
of antidepressants. They act by slowing the reuptake of serotonin by presynaptic
terminals, and include fluoxetine, sertraline. and paroxetine. Because SSRIs lack
cardiovascular complications. do not cause anticholinergic side effects such as
dry mouth and constipation. are less dangerous with respect to overdosing, and
do not interfere with cognitive functioning, they may have significant advantages
over tricyclics and MAOIs in the treatment of elderly patients (Dunner, 1994;
Preskorn. 1993). They may be particularly useful for individuals exhibiting symp-
toms of inertia, extreme fatigue, and lack of motivation (Salzman, 1994).
Outcome Studies. Comparison of fluoxetine and doxepin in elderly pa-

tients found the two drugs to be equally efficacious. Common side effects of flu-
oxetine included nervousness or anxiety, or both. and nausea, although
fluoxetine appeared to be better tolerated than doxepin (Feighner & Cohn,
1985). Dunner and colleagues (1992) compared paroxetine and doxepin in two
double-blind studies, and found both to be effective in reducing symptoms of
depression, with fewer and less severe side effects in paroxetine. One recent
study comparing fluoxetine to paroxetine in elderly patients found paroxetine
Depression 211
to be significantly more effective, with the two drugs equally well tolerated
(Geretsegger, Bohmer, & Ludwig, 1994).
Risks and Can train dica tions. Use of SSRIs should not overlap with
MAOIs, because the interaction between the two drugs can be fatal. Because of
the particularly long half life of SSRIs. a washout period of at least 5 weeks is
necessary before treatment with MAOIs is begun (Preskorn, 1993).
Comment
Antidepressant medications should be considered in the treatment of de-
pressed elders. As the research discussed above indicates. medication should
be selected carefully to minimize medical risk and distressing side effects, and
should be regularly monitored. Further research on the use of antidepressants
remains to be done, particularly in the treatment of medically ill patients and
those of very advanced age. Also. most outcome studies report effectiveness of
antidepressant treatment in isolation, rather than in conjunction with other
forms of intervention such as psychotherapy. Further research into such com-
binations may reveal that medication alone is not the best course of treatment
for depression in the elderly.
SUMMARY
The discussion of depression in older adults in this chapter is based on the
literature that exists at the time of writing. From this literature, we know that
depressive disorders in older adults vary in their prevalence. Older adults seen
in medical clinics and nursing homes have higher rates of depression than do
older adults sampled from the community. In addition. we know that older
adults exhibit agitation, relatively higher rates of appetite and sleep distur-
bance, hopelessness, and guilt when they are depressed. We also know that
there may be a unique type of depression in late life with its own etiology and
prognosis. Many methods for treating these disorders exist and are generally
successful in alleviating symptoms of depression. We still need to study issues
such as the roles that gender and ethnicity have on the development, presenta-
tion, and treatment of depressive disorders, whether some methods of treating
depression in older adults are more useful than others, and how effective these
interventions are in treating depressive disorders in special populations (e.g.,
medically ill or frail elderly people). Research on these questions should help
to further shape our understanding of depressive disorders in late life.
REFERENCES
Abramson, L. H., Metalsky, G. I., & Alloy, L. B. (1989). Hopelessness depression: A theory based
subtype of depression. Psychological Review, 96, 358-372.
Achte, K. (1988). Suicidal tendencies in the elderly. Suicide and Life-Threatening Behavior, 18,
55-65.
Alexopoulos, G. S., Young, R., Meyers, B., Abrams, R., & Shamoian, C. (1988). Late onset depres-
sion. Psychiatric Clinics of North America, 11 (1), 101-115.
Altshuler, K. Z. (1989). Will the psychotherapies yield differential results? American Journal of Psy-
chiatIJ!, 43, 310-320.
American Psychiatric Association (APA Task Force on ECT). (1990). The practice of electroconvul-
sive therapy: Recommendations for treatment, training, and privileging. Washington, DC:
American Psychiatric Press.
Arean, P. A., & Miranda, J. (1997). The utility of the Center for Epidemiological Studies-Depres-
sion Scale in older primary care patients. Aging {7 Mental Health, 1(1),47-56.
Arean, P. A., & Miranda, J. (1995, September). Prevalence and comorbidity of psychiatric disorders
in low-income elderly. Paper presented at the Ninth International Conference of Mental Health
Service Research, Bethesda, MD.
Arean, P. A., Perri, M. G., Nezu, A. M., Schein, R. L., Christopher, F.. & Joseph, T. X. (1993). Com-
parative effectiveness of social problem-solving therapy and reminiscence therapy as treat-
ments for depression in older adults. Journal of Consulting and Clinical Psychology, 61(6),
1003-1010.
Baldwin, R. & Jolley, D. (1986). The prognosis of depression in old age. British Journal of Psychia-
tIJ!, 149,574-583.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J.. & Erbaugh, J. (1961). An inventory for measuring
depression. Archives of General Psychiatry, 4, 561-571.
Beck, A. T., Rush, A. J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York:
Guilford.
Beutler, L. E., Scogin, F., Kirkish, P., Schretlen, D., Corbishley, A., Hamblin. D., Meredith, K., Potter,
R., Bamford, C. R., & Levenson, A. I. (1987). Group cognitive therapy and Alprazolam in the
treatment of depression in older adults. Journal of Consulting and Clinical Psychology, 55,
550-556.
Birren, J. E., & Deutchman, D. E. (1991). Guiding autobiography groups for older adults: Exploring
the fabric of life. Baltimore: Johns Hopkins University Press.
Blazer, D. (1990). Emotional problems in later life: Intervention strategies for professional care-
givers. New York: Springer.
Blazer, D. G., Bachar, J. R., & Hughes, D. C. (1987). Major depression with melancholia: A compari-
son of middle-aged and elderly adults. Journal of the American Geriatrics Society, 35. 927-932.
Blum, J. E., & Tross, S. (1988). Psychodynamic treatment of the elderly: A review of issues in theory
and practice. In C. Eisdorfer (Ed.), Annual Review of Geronto]ogy and Geriatrics (vol. 1). New
York: Springer.
Brink, T. L.• Yesavage, J. A .• Lum, 0 .. Heersema. P. H .• Adey, M .• & Rose. T. L. (1982). Screening tests
for geriatric depression. Clinical Gerontologist, 1.37-43.
Brodaty. H .• Harris. L.• Peters. K.. Wilhelm, K.. Rickie. I.. Boyce. P.• Mitchell. P.. Parker. G.. & Eyers.
K. (1993). PrognosiS of depression in the elderly: A comparison to younger patients. British
Journal of PsychiatIJ!, 163.589-596.
Brown, R. P.• Sweeney. J.• Loutsch. E.• Kocsis. J., & Frances. A. (1984). Involutional melancholia re-
visited. American Journal of PsychiatIJ!, 141, 24-28.
Burke. W. J.• Rubin. E. H .• Zorumski. C. F., & Wetzel. R. D. (1987). The safety ofECT in geriatric psy-
chiatry. Journal of the American Geriatrics Society, 35, 516-21.
Caine, E. D.• Lyness. J. M .• King, D. A .• & Conners. L. (1991). Clinical and etiological heterogeneity
of mood disorders in elderly patients. In L. S. Schneider. C. F. Reynolds. B. Lebowitz. & A.
FriedHoff. (Eds.). DiagnOSiS and treatment of depression in late-life: Results of the NIH con-
sensus development conference. Washington. DC: American Psychiatric Press.
Callahan. C. M .• Hui, S. L., Nienaber. N. A .• Musick. B. S .• & Tierney, W. M. (1994). Longitudinal
study of depression and health services use among elderly primary care patients. Journal of
the American Geriatrics Society, 42, 833-838.
Cohn. C. K.• Shrivastava. R.. Mendels. J.• Cohn. J. B., Fabre, L.• Claghorn. J. L.. Dessain. E. C., Itil. T.
M., & Lautin. A. (1990). Double-blind. multicenter comparison of sertraline and amitriptyline
in elderly depressed patients. Journal of Clinical Psychiatry, 51, (Supp. B), 28-33.
Curb. J. D.• Guralnik. J. M .• LaCroix. A. Z .• Korper. S. P.• Deeg. D., Miles, T.• & White. L. (1990). Ef-
fective aging: Meeting the challenge of growing older. Journal of the American Geriatric Soci-
ety, 38, 827-828.
Depression 213
Depue. R. A .• & Monroe. S. M. (1978). Learned helplessness in the perspective of the depressive dis-
orders: Conceptual and definitional issues. Abnormal Psychology. 87. 3-20.
Devanand. D. P.• Nobler. M. S .• Singer. T.. Kiersky. J. E.• Turret. N.. Roose. S. P.. & Sackeim. H. A.
(1994). Is dysthymia a different disorder in the elderly? American Journal of Psychiatry. 151
(11).1592-1599.
Disch. R. (Ed.). (1988). Twenty-five years of life review: Theoretical and practical considerations.
Journal of Gerontological Social Work. 12 [Special issueI1-148.
Dreyfus. J. K. (1988). Depression assessment and interventions in medically ill frail elderly. Jour-
nal of Gerontological Nursing. 14. 27-36.
Dunn. V. K.. & Sacco. W. P. (1989). Psychometric properties ofthe Geriatric Depression Scale and
the Zung Self-Rating Depression Scale using an elderly community sample. Psychology and
Aging. 4 (1). 125-126.
Dunner. D. 1. (1994). Therapeutic considerations in treating depression in the elderly. Journal of
Clinical Psychiatry. 55 (Supp.). 48-58.
Dunner. D. 1.. Cohn. J. B.. Walsh. T.• Cohn. C. K.. Feighner. J. P.. Fieve. R. R.. Halikas. J. P.. Hartford.
J. T.. Hearst. E. D.. Settle. E. C.. Menolascino. F. J.. & Muller. D. J. (1992). Two combined. mul-
ticenter double-blind studies of paroxetine and doxepin in geriatric patients with major de-
pression. Journal of Clinical Psychiatry. 53 (Supp.). 57-60.
Erikson. E. H. (1959). Identity and the life cycle. New York: Norton.
Evans. M. E.. Copeland. J. R. M.. & Dewey. M. E.. (1991). Depression in the elderly in the commu-
nity: Effect of physical illness and selected social factors. International Journal of Geriatric
Psychiatry. 6. 787-795.
Feighner. J. P.. & Cohn. J. B. (1985). Double-blind comparative trials of fluoxetine and doxepin in
geriatric patients with major depressive disorder. Journal of Clinical Psychiatry. 46. 20-25.
First. M. (1994). Structured Clinical Interview for DSM-IV.
Frank. E.. Frank. N.. Comes. C.. Imber. S. D.. Miller. M. D.. Morris. S. M.. & Reynolds. C. F. (1993).
Interpersonal psychotherapy in the treatment of late-life depression. In G. L. Klerman & M. M.
Weissman (Eds.). New applications of interpersonal psychotherapy (pp. 167-198). Washing-
ton. DC: American Psychiatric Press.
Freud. S. (1959). On psychotherapy. In S. J. London (Ed.). The standard edition of the complete psy-
chological works of Sigmund Freud (Vol. 7. pp. 257-268). London: Hogarth. (Original work
published 1905)
Fry. P. (1989). Mediators of perceptions of stress among community elders. Psychological Reports.
65. 307-314.
Gallagher. D. (1986). Assessment of depression by interview methods and psychiatric rating scales.
In 1. W. Poon (Ed.). Handbook for clinical memory assessment of older adults (pp. 202-212).
Washington. DC: American Psychological Association.
Gallagher. D.. & Thompson. 1. (1982). Treatment of major depressive disorder in older adult outpa-
tients with brief psychotherapies. Psychotherapy: Theory. Research. and Practice. 19. 482-490.
Gallagher-Thompson. D.. & Thompson. L. W. (1992). The older adult. In A. Freeman & F. Dattilio
(Eds.). Comprehensive casebook of cognitive therapy (pp. 193-200). New York: Plenum.
Gallo. J. J.. Anthony. J. C.• & Muthen. B. O. (1994). Age differences in the symptoms of depression:
A latent trait analysis. Journal of Gerontology: Psychological Issues. 49 (6). P251-P264.
Ganzini. 1.. Lee. M. A .. Heintz. R. T.. Bloom. J. D.. & Fenn. D. S. (1994). The effects of depression
treatment on elderly patients' preferences for life-sustaining medical therapy. American Jour-
nal of Psychiatry. 151 (11).1631-1636.
George. L. K. (1989). Stress. social support. and depression over the life course. In K. S. Markides &
C. L. Cooper (Eds.). Aging. stress. and health. New York: Wiley.
Georgotas. A .. McCue. R. E.• Friedman. E.. & Cooper. T. (1987). Response of depressive symptoms to
nortriptyline. phenelzine. and placebo. British Journal of Psychiatry. 151,102-107.
Geretsegger. C.. Bohmer. F.. & Ludwig. M. (1994). Partoxetine in the elderly depressed patient: Ran-
domized comparison with fluoxetine of efficacy. cognitive and behavioural effects. Interna-
tional Clinical Psychopharmacology, 9. 25-29.
Glassman. A. R .• & Roose. S. P. (1994). Risks of antidepressants in the elderly: Tricyclic antidepres-
sants and arrhythmia-revising risks. Gerontology. 40 (Supp. 1). 15-20.
Goldman. L. S. (1986). Monoamine oxidase inhibitors and tricyclic antidepressants: Comparison
of their cardiovascular effects. Journal of Clinical Psychiatry. 47. 225-229.
214 Patricia A. AreaD et 01.
Goldman. L. S.. Alexander. R. C.. & Luchins. D. J. (1986). MAOIs and tricylic antidepressants: Com-
parison of their cardiovascular effects. Journal of Clinical Psychiatry, 47(5). 225-229.
Gurland. B. (1997). The Comprehensive Assessment and Referral Evaluation (CARE): Rationale. de-
velopment and reliability. International Journal of Aging and Human Development. 8 (1). 9-42.
Gurland. B. J.• Copeland. J. R.. Kurlansky. J.. Kelleher. M. J.• & Sharpe. L. (1983). The mind and
mood of aging. New York: Hawthorne Press.
Haight. B. K. (1992). Long-term effects of a structured life review process. Journal of Gerontology:
Psychological Sciences Section. 47. 312-315.
Hamilton. M. (1960). A rating scale for depression. Journal of Neurology. Neurosurgery and Psychi-
atry. 23. 56-62.
Hamilton. M. (1986). The Hamilton Rating Scale for Depression. In N. Sartorius & T. A. Ban (Eds.).
Assessment of depression. New York: Springer-Verlag.
Henderson. A. S. (1989). Psychiatric epidemiology and the elderly. International Journal of Geri-
atric Psychiatry, 4. 249-253.
Hickie. C.• & Snowdon. J. (1987). Depression scales in the elderly: Geriatric Depression Scale Gil-
leard. Zung. Clinical Gerontologist. 6 (3).51-53.
Husaini. B. A .• Moore. S. T.• Castor. R. S .• Neser. W.• Whitten-Stovall. R.. Linn. G.. & Griffin. D.
(1991). Social density. stressors. and depression: Gender differences among Black elderly.
Journals of Gerontology: Psychological Sciences. 46 (5). P236-P242.
Karlinsky. H .• & Schulman. K. I. (1984). The clinical use of electroconvulsive therapy in old age.
Journal of the American Geriatrics Society. 32. 183-186.
Klerman. G. L. (1989). Efficacy of a brief psychosocial interventions for symptoms of stress and dis-
tress in primary care. Medical Care. 25 (11). 1078-1088.
Klerman. G. L.• Weissman. M. M.• & Rounsaville. B. J.• (1984). Interpersonal psychotherapy of de-
pression. New York: Basic Books.
Koenig. H. G.• & Blazer. D. G (1992). Epidemiology of geriatric affective disorders. Clinics in Geri-
atric Medicine. 8 (2). 235-251.
Koenig. H. G.• Blazer. D. G.• Cohen. H. J.. Meador. K. G.• & Westlund. R. (1992). A Briez depression
scale for use in the medically ill. International Journal of Psychiatry in Medicine. 22(2).
183-195.
Koenig. H. G.• Veeraindar. G.• Shelp. F.. Kundler. H. S .• Cohen. H. J.. Meador. K. G. & Blazer. D. G.
(1989). Antidepressant use in elderly medical inpatients: Lessons from an attempted clinical
trial. Journal of General Internal Medicine. 4. 499-508.
Kramer. B. A. (1987). Electroconvulsive therapy use in geriatric depression. Journal of Nervous and
Mental Disease. 175. 233-235.
Krause. N. (1987). Life stress. social support. and self-esteem in an elderly population. Psychology
and Aging. 2.185-192.
Krishnan. K. R. R. (1991). Organic bases of depression in the elderly. Annual Review of Medicine.
42. 261-266.
Krishnan. K.. Doraiswamy. P.• Fifiel. G.• Husain. M. (1991). Hippocampal abnormalities in depres-
sion. Journal of Neuropsychiatry and Clinical Neuroscience. 3 (4). 387-391.
Lazarus. L. W.• Groves. L.• Newton. N.• Gutmann. D.• Ripeckyj. A .. Frankel. R.. Grunes. J.• & Havasy-
Galloway. S. (1984). Brief psychotherapy with the elderly: A review and preliminary study of
process and outcome. In L. W Lazarus (Ed.). Clinical approaches to psychotherapy with the el-
derly (pp. 15-35). Washington. DC: American Psychiatric Press.
Lazarus. L. W.• Groves. L.• Gutmann. D.• Ripeckyj. A.• Frankel. R.. Newton. N.• Grunes. J.. & Havasy-
Galloway. S. (1987). Brief psychotherapy with the elderly: A study of process and outcome. In
J. Sadavoy & M. Leszcz (Eds.). 'freating the elderly with psychotherapy (pp. 265-293). Madi-
son. CT: International Universities Press.
Lazarus. R. (1986). Coping Strategies. In S. McHugh & T. M. Vallis (Eds.). Illness behavior: A multi-
disciplinary approach. New York: Plenum.
Lazarus. R. S .• & Folkman. S. (1984). Stress. appraisal. and coping. New York: Springer.
Lewinsohn. P. M.• Biglan. T.. & Zeiss. A. (1976). Behavioral treatment of depression. In P. Davidson
(Ed.). Behavioral management of anxiety. depression. and pain (pp. 91-146). New York:
BrunerlMazel.
Lewis. C. N .• & Butler. R. N. (1974). Life review therapy: Putting memories to work in individual
and group therapy. Geriatrics. 29. 165-173.
Depression 215
Markides. K.. & Cooper. C. (1989). Aging. stress. and health. New York: Wiley.
Massie. M. J.• Gagnon. P.• & Holland. J. C. (1994). Depression and suicide in patients with cancer.
Journal of Pain and Symptom Management. 9 (5). 325-340.
McCue. R. E. (1992). Using tricyclic antidepressants in the elderly. Clinics in Geriatric Medicine. 8.
323-334.
Mendels. J. (1993). Clinical management of the depressed geriatric patient: Current therapeutic op-
tions. American Journal of Medicine. 94 (Supp. 5A). 13S-18S.
Myers. W. A. (1991). Psychoanalytic psychotherapy and psychoanalysis with older patients. In
W. A. Myers (Ed.). New techniques in the therapy of older patients. Washington. DC: Ameri-
can Psychiatric Press.
National Institutes of Health (NIH) Consensus Development Panel on Depression in Late Life.
(1992). Diagnosis and treatment of depression in late life. Journal of the American Medical As-
sociation. 268. 1018-1024.
Neese. J. B. (1991). Depression in the general hospital. Nursing Clinics of North America. 26.
613-622.
Newmann. J. P. (1989). Aging and depression. Psychology and Aging. 4. 150-166.
Parmalee. P.• Katz. I.. & Lawton. P. (1989). Depression among institutionalized aged: Assessment
and prevalence estimation. Journals of Gerontology, 44, M22-M29.
Parmalee. P. A.• Katz. I. R.. & Lawton. M. P. (1991). The relation of pain to depression among insti-
tutionalized aged. Journals of Gerontology, 46. 15-21.
Preskorn, S. H. (1993). Recent pharmacologic advances in antidepressant therapy for the elderly.
American Journal of Medicine, 94, S(Supp. 5A). 25-12S.
Radloff. L. S. (1977). The CES-D scale: a self-report depression scale for research in the general pop-
ulation. Applied Psychological Measurement, 1, 385-401.
Rattenberg. C.• & Stones, M. J. (1989). A controlled evaluation of reminiscence and current topics
discussion groups in a nursing home context. The Gerontologist, 29(6). 768-777.
Regier, D. A.• Hirschfeld. R. M. A.• Goodwin. F. K.. Burke. J. D.• Lazar. J. B.• & Judd. L. L. (1988). The
NIMH Depression Awareness. recognition and treatment program: Structure. aims and scien-
tific basis. American Journal of Psychiatry. 145(11). 1351-1357.
Rice. E. H .• Sombrotto. L. B.• Markowitz. J. C.• & Leon. A. C. (1994). Cardiovascular morbidity in
high-risk patients during ECT. American Journal of Psychiatry. 151, 1637-1641.
Rickels. K.• & Schweizer. E. (1993). Anxiolytics: Indications. benefits and risks of short and long
term benzdiazepine therapy: Current research data. NIDA Research Monographs, 131,51-67.
Robins. L. N.• Helzer. J. E.• Croughan. J.• & Ratcliff. K. s. (1981). National Institute of Mental Health
Diagnostic Interview Schedule: Its history. characteristics. and validity. Archives of General
Psychiatry. 38, 381-389.
Robins. L. N.• Helzer. J. E.• Weissman. M. M.• Orvaschel. H.• Gruenberg. E.• Burke. J. D.• & Regier.
D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of
General Psychiatry. 41. 949-958.
Robinson. R. G.• & Price. T. R. (1982). Post-stroke depressive disorders: A follow-up of 103 patients.
Stroke, 13, 335-341.
Rubin. E. H.• Kinscherf. D. A.• Figiel. G. S.• & Zorumski. C. F. (1993). The nature and time course of
cognitive side effects during ECT in the elderly. Journal of Geriatric Psychiatry and Neurology,
6(2). 78-83.
Ruthazer. R.. & Lipsitz. L. (1993). Antidepressants and falls among elderly people in long-term care.
American Journal of Public Health. 83, 746-49.
Salzman. C. (1992). Monoamine oxidase inhibitors and atypical antidepressants. Clinics in Geriatric
Medicine, 8(2). 335-348.
Salzman. C. (1994). Pharmacological treatment of depression in elderly patients. In L. Schneider. C.
Reynolds. B. Lebowitz. & A. J. Friedhoff (Eds.). Diagnosis and treatment of depression in late
life: Results of the NIH Consensus Development Conference. (pp. 181-244). Washington. DC:
Schneider. L. S.. Sloane. R. B.• Staples. F. R.. & Bender. M. (1986). Pre-treatment orthostatic hy-
potension as a predictor of response to nortriptyline in geriatric depression. Journal of Clini-
cal Psychopharmacology, 6, 172-176.
Scogin. F.. & McElreath. L. (1994). Efficacy of psychosocial treatments for geriatric depression: A
quantitative review. JCCP. Journal of Consulting and Clinical Psychology, 62 (1). 69-74.
Shapiro. R. N.• & Keller. M. B. (1981). Initial6-month follow-up of patients with major depressive
disorders. Journal of Affective Disorders. 3(3). 205-220.
Smyer. M.• Zarit. S.• & Qualls. S. H. (1990). Psychological intervention with the aging individual. In
J. Birren & K. W. Schaie (Eds.). Handbook of the psychology of aging (3rd ed .. pp. 375-403).
New York: Academic.
Spitzer. R. L.• Williams. J. B. W.• Gibbon. M.• & First. M. B. (1988). Structured clinical interview for
DSM-III-R Patient Version (SCID-P 6/1/88). New York: Biometrics Research Department. New
York State Psychiatric Institute.
Stoudemire. A.• Moran. M. G.• & Fogel. B. S. (1991). Psychotropic drug use in the medically ill. Part
n. Psychosomatics. 32(1). 34-46.
Teri. L.• Curtis. J.. Gallagher-Thompson. D.• & Thompson. L. W. (1994). Cognitive/behavioral ther-
apy with depressed older adults. In L. S. Schneider. C. F. Reynolds. B. Lebowitz. & A. Fried-
hoff (Eds.). Diagnosis and treatment of depression in late life. Washington DC: American
Psychiatric Press.
Thompson. L. W.• & Gallagher-Thompson. D. (1993. November). Comparison of Desipramine and
cognitive-behavioral therapy in the treatment of late- life depression: A progress report. Pa-
per presented at the 27th annual American Association of Behavior Therapy Convention. At-
1anta. GA.
Thompson. L. W.• Gallagher. D.• & Breckenridge. J. S. (1987). Comparative effectiveness of psy-
chotherapy for depressed elders. Journal of Consulting and Clinical Psychology. 55 (3).
385-390.
Volz. H.-P.• & Moller. H.-J. (1994). Antidepressant drug therapy in the Elderly-A critical review of
the controlled clinical trials since 1980. Pharmacopsychiatry. 27. 93-100.
Weaver. T. E.• & Narsavage. G. L. (1992). Physiological and psychological variables related to nmc-
tional status in chronic obstructive pulmonary disease. Nursing Research. 41. 286-191.
Weiner. R. D. (1992). The role of electroconvulsive therapy in the treatment of depression in the el-
derly. Journal of the American Geriatrics Society. 30. 710-712.
Weiss. I. K.. Nagel. C. L.. & Aronson. M. K. (1986). Applicability of depression scales to the old old
person. Journal of the American Geriatric Association. 34(3). 215-218.
Weiss. L. J.• & Lazarus. 1. W. (1993). Psychosocial treatment ofthe geropsychiatric patient. Interna-
tional Journal of Geriatric Psychiatry. 8. 95-100.
Yost. E. B.• Beutler. L. E.• Corbishely. M. A.• & Allender. J. 1. (1986). Group cognitive therapy: A
treatment manual for depressed older adults. New York: Pergamon.
Zung. W. W. K. (1965). A self-rating depression scale. Archives of General Psychiatry. 12.63-70.
CHAPTER 11
Anxiety Disorders
MELINDA A. STANLEY AND J. GAYLE BECK
INTRODUCTION
In the past two decades, major advances have been made regarding the psy-
chopathology and treatment of anxiety disorders (Barlow, 1988; Beidel & Turner,
1991). The negative impact of these disorders on life function has been well docu-
mented, and epidemiological data have suggested that anxiety disorders comprise
the second most common form of psychiatric disturbance over the lifetime in the
United States, following only substance abuse disorders (Robins et al., 1984). De-
spite the voluminous amount of data available regarding anxiety disorders in the
general population, however, the nature and treatment of these in older adults has
received relatively little empirical attention. The need for additional work in this
area has been emphasized on many occasions (e.g., Carstensen, 1988; Hersen &
Van Hasselt, 1992; Salzman & Lebowitz, 1991), and a small body ofrelevant liter-
ature has begun to accumulate. The purpose of this chapter is to review the avail-
able scientific literature that addresses the epidemiology, psychopathology,
assessment, and treatment of anxiety in the elderly. Given that this literature is in
an early developmental stage, directions for future research also are suggested.
EPIDEMIOLOGY
Prevalence
As noted, the National Institute of Mental Health (NIMH) Epidemiological

Catchment Area (ECA) survey conducted during the 1980s found that across all
age groups surveyed, lifetime prevalence rates for anxiety disorders in the
United States were second only to those for substance abuse disorders (Robins
MELINDA A. STANLEY • Department of Psychiatry and Behavioral Sciences, University of Texas Men-
tal Sciences Institute, Health Science Center at Houston, Houston, Texas 77030. J. GAYLE BECK
• Department of Psychology, State University of New York, Buffalo, New York 14260.
217
218 Melinda A. Stanley and J. Gayle Beck
et a1., 1984). When 1-month prevalence rates were examined, anxiety disorders
actually were the most prevalent of all groups of psychiatric conditions (Regier
et a1., 1988; Regier, Narrow, & Rae, 1990). A similar pattern emerged when data
were examined for the 30.7% of participants who were 65 years of age or older
(n = 5702). In this group, anxiety disorders also were most common, with a
1-month prevalence rate of 5.5% across five sites (Regier et a1., 1988, 1990). The
majority of anxiety disorders assigned were classified as phobias (4.8%), in-
cluding agoraphobia, social phobia, and simple phobia. Much lower prevalence
rates were recorded for obsessive-compulsive disorder (0.8%) and panic disor-
der (0.1 %). Six-month prevalence rates from the Yale University site, which
oversampled older adults (n = 2588), were similar (Weissman et a1., 1985). At
this site. an overall rate of 4.6% was found for anxiety disorders in older adults,
with 3.9% of diagnoses classified as phobias, 0.7% as obsessive-compulsive
disorder, and 0.1 % as panic disorder.
It is notable that Wave I of the ECA survey, conducted in 1982 and 1983,
omitted consideration of prevalence rates for posttraumatic stress disorder
(PTSD) and generalized anxiety disorder (GAD). (GAD was omitted because it
had not been recognized as a distinct psychiatric entity at the time [American
Psychiatric Association, 1980]). In Wave II of the survey, conducted 1 year later,
a subset of participants were reinterviewed, with questions included to address
the prevalence of PTSD and GAD. Data from the Duke University site, wherein
older adults were oversampled, indicated 6-month and lifetime prevalence rates
of 1.9% and 4.6% for GAD in adults aged 65 years or older (Blazer, George, &
Hughes, 1991). These figures omitted consideration of individuals with a con-
current diagnosis of major depression or panic disorder, however, and thus may
have underestimated the true prevalence of GAD. (Only overall population
prevalence estimates were provided for PTSD [Helzer, Robins, & McEvoy, 1987].)
In a review of ECA data and seven other community surveys that provided
figures for older adults (aged 60 years and older), overall prevalence rates for
anxiety disorders ranged from 0.7% to 18.6% (Flint, 1994). Prevalence rates for
phobic disorders ranged from 0.0% to 10.0%, GAD from 0.7% to 7.1 %, obses-
sive-compulsive disorder from 0.0% to 1.5%, and panic disorder from 0.1 % to
1.0%. The wide variations in rates for some disorders likely results from the
range of survey methods, case definitions, and diagnostic procedures used to es-
tablish anxiety disorder diagnoses (Flint. 1994). For example, some surveys uti-
lized self-report measures to establish diagnoses, whereas others relied on
semistructured clinical interviews. In addition. some diagnostic criteria were
based on widely accepted standards (e.g .• American Psychiatric Association,
1980), while others used more idiosyncratic procedures. As a result, although
criticisms have been registered regarding the methodology used in the ECA sur-
vey (Beidel & Turner, 1991; McNally, 1994), these data represent the best figures
currently available to estimate the prevalence of anxiety disorders in the elderly.
ECA data consistently have indicated that prevalence rates for anxiety dis-
orders in older adults are lower than those from younger adult samples (Blazer
et a1., 1991; Regier et a1., 1988). Nonetheless, the figures just noted indicate that
anxiety disorders pose a significant mental health problem for the elderly. In
addition, ECA data may have underestimated the percentage of older adults
with significant anxiety problems given the tendency of these individuals to
Anxiety Disorders 219
underreport psychological symptoms (Oxman, Barrett, Barrett, & Gerber, 1987).

For some time, depression in older persons has been emphasized as a serious
public health issue (Reynolds, Lebowitz, & Schneider, 1993). However, ECA
Wave I data attested that anxiety disorders in this population (excluding GAD)
are more than twice as prevalent as affective disorders, in general, and 4 to 8
times more frequent than major depression (Regier et aI., 1988; Weissman et al.,
1985). When estimated prevalence rates for GAD are added, anxiety disorders
emerge as an even more serious concern for the growing population of elders in
the United States.
In addition to epidemiological investigations focusing on the prevalence of
diagnosable anxiety disorders, another set of studies has addressed the fre-
quency of distressing anxiety symptoms in older adults. These surveys have uti-
lized standardized self-report inventories, such as the Hopkins Symptoms
Checklist (HSCL; Derogatis, Lipman, Rickels, Uhlenhuth, & Covi, 1973) and the
Spielberger Trait Anxiety Inventory (STAI; C. Spielberger, Gorsuch, & Lushene,
1970), to identify individuals with significant anxiety symptoms, using cutoff
scores based on standard deviations from mean scores in normal and psychi-
atric samples. This type of methodology has yielded prevalence rates of 16.3%
to 20.0% in community samples (Feinson & Thoits, 1986; Himmelfarb & Mur-
rell, 1984) and 8.0% to 10.0% in a primary care setting (Oxman et al., 1987).
When relevant comparisons have been made. these figures again suggest that
the prevalence of anxiety in older adults generally is lower than in younger
adult samples (Feinson & Thoits, 1986; Oxman et al., 1987). although a sub-
stantial number of older persons report distressing symptoms in this domain.
Age of Onset
At least two reports have suggested that many phobias in older adults are of
recent onset (Eaton et aI., 1989; Lindesay. 1991). In the ECA study, for example,
estimated incidence figures for phobias were unrelated to age. with similar fre-
quencies of onset across age groups over a i-year period (Eaton et aI., 1989). In
another community survey of older adults, simple phobias generally were re-
ported to have their onset in childhood (Lindesay. 1991), as has been reported in
the younger adult literature (Thyer, Parrish. Curtis. Nesse. & Cameron. 1985).
However, the majority of older adults with agoraphobic fears (e.g .• of enclosed
places, crowds. public transportation, going away from home) indicated recent
onset, most often following an episode of physical illness (e.g .. myocardial in-
farction, fractures, cerebrovascular accident) or traumatic experience (e.g .• mug-
gings, a fall at home). Given the types of onset frequently reported in this sample,
diagnoses of agoraphobia in some cases may be questioned. Specifically, realis-
tic fears or physical limitations rather than anticipation of panic may have mo-
tivated the symptoms reported (see McNally, 1994, for a similar discussion of
diagnostic issues in younger adults). Further. a high incidence of depression in
Lindesay's (1991) sample suggests that agoraphobic fears reported by partici-
pants in this study may have represented social withdrawal associated with de-
pressive symptomatology (Flint, 1994). Therefore, conclusions regarding onset
of phobias in the elderly from this report should be interpreted cautiously.
EGA data implied that panic disorder and obsessive-compulsive disorder,

which occurred infrequently in community samples of older adults, typically
did not begin in older age (Eaton et aI., 1989). In a chart review of 51 elderly
clinic patients with panic disorder, however, Raj, Gorvea, and Dagon (1993)
found that more than half of the sample reported onset at age 60 years or later.
No notable differences between older adults with late-onset or early-onset (Le.,
at age 59 or younger) panic disorder were reported.
According to EGA Wave II data, age of onset for GAD in older persons ap-
pears to have a bimodal distribution, with 39% of patients reporting a duration
of 21 years or more and 50% reporting onset within the prior 5 years (Blazer et
aI., 1991). A similar biomodal distribution of onset was obtained in a clinical
sample of older adults with GAD (Beck, Stanley, & Zebb, 1996). In this report,
few differences in psychopathological features (e.g., anxiety, depression, fears)
were noted in a comparison of early- and late-onset subsamples.
Demographic Correlates
As has been demonstrated in younger adults (Regier et aI., 1990), anxiety

disorders in older individuals generally occur more often in women than men,
with a particularly large male/female ratio for phobic disorders (e.g., Blazer et
aI., 1991; Regier et aI., 1988; Weissman et aI., 1985). A similar pattern has been
found in surveys targeting prevalence of anxiety symptoms rather than disor-
ders. For example, in two community surveys, more women than men met
preestablished cutoffs for notable anxiety symptoms (e.g., Himmelfarb & Mur-
rell, 1984), and women reported greater overall fearfulness than men (Liddell,
Locker, & Burman, 1991).
With regard to ethnic distribution, problems with sampling strategies for
some minority groups in the EGA studies have been noted (Beidel & Turner,
1991), making it difficult to draw conclusions about the relationship between
ethnicity and the prevalence of anxiety disorders in any age group. Among
older adults, Weissman and colleagues (1985) reported lower rates of psychi-
atric disorders in general among blacks than among whites, although similar
data were not made available for anxiety disorders separately. EGA Wave II
data, however, indicated equivalent prevalence rates of GAD in older black and
white adults (Blazer et aI., 1991). Two survey studies assessing the prevalence
of anxiety symptoms in older adults reported no significant relationship be-
tween anxiety and ethnicity (Feinson & Thoits, 1986; Himmelfarb & Murrell,
1984), although in one of these studies, minority groups were underrepresented
relative to the general population (Feinson & Thoits, 1986), and in the other, no
data regarding ethnic distribution of the sample were provided (Himmelfarb &
Murrell, 1984). Further research in this domain is clearly warranted.
Prevalence and/or severity of anxiety symptoms in older adults also has
been related to marital status, with fewer symptoms reported by married per-
sons than unmarried persons (Feinson & Thoits, 1986). A more complicated re-
lationship between marital status, gender, and anxiety symptoms among the
elderly was demonstrated by Himmelfarb and Murrell (1984), with highest lev-
els of anxiety among never-married men and lowest anxiety scores among
never-married women. Finally, significant inverse relationships have been

noted between income and anxiety among the elderly (Feinson & Thoits, 1986;
Himmelfarb & Murrell, 1984; Liddell et a1., 1991), and in some cases between
educational attainment and anxiety (Himmelfarb & Murrell, 1984; Liddell et aI.,
1991). These patterns are similar to relationships demonstrated among younger
adults with anxiety disorders (Regier et a1., 1990).
PSYCHOPATHOLOGY
Much is known about the psychopathology of anxiety disorders in younger

adults, although a full review of this literature is beyond the scope of this chap-
ter (see reviews by Barlow, 1988; Beidel & Thrner, 1991; Rapee & Barlow, 1991).
However, an overview of issues relevant to unique aspects of anxiety in older
adults is provided here.
Nature of Anxiety
A number of issues deserve special attention in the diagnosis of anxiety

disorders in the elderly. First, differentiating physiological symptoms of anxi-
ety from the medical problems that often are associated with advancing age
needs to be considered carefully. This issue is particularly important given that
older adults often attribute anxiety-related difficulties to physical illnesses and
consequently deny symptoms or seek treatment in a primary care facility rather
than a psychiatric clinic (Gurian & Miner, 1991). Consequently, primary care
physicians need to be aware of the signs and symptoms of anxiety in their pa-
tients, providing appropriate treatment or referrals when warranted. Similarly,
clinicians in psychiatric settings need to be careful not to attribute somatic com-
plaints to anxiety difficulties when diagnosis and treatment of a medical con-
dition might alleviate reported symptoms. Second, careful attention needs to be
paid to differentiating anxiety disorders from realistic fears that may accom-
pany the aging process. In this case, qualifiers used regularly to describe fears
that meet criteria for anxiety disorders (e.g., "excessive," "unrealistic") need to
be considered carefully in light of real-life circumstances that may exist for
older individuals, such as decreasing independence and increasing health
problems. It can be tempting for practitioners, however, to overattribute anxiety
and fears in older adults to the normal aging process, thereby overlooking or ig-
noring treatable psychiatric symptomatology (Weiss, 1994). In this regard, ex-
amination of normal versus abnormal fears in elderly samples becomes
paramount. A small body of literature has begun to address this issue.
The majority of work examining the nature of fears in older persons has fo-
cused on worry, most likely because generalized anxiety is one of the most
prevalent forms of anxiety observed in older adults (Blazer et aI., 1991). Avail-
able studies have assessed characteristics of worry in both normal, community
samples and diagnosed clinical groups. In one community survey of worry top-
ics among adults, Person and Borkovec (1995) categorized participants' "most
important problems, worries or concerns" into five categories: (1) family-home-
interpersonal, (2) illness-health-injury, (3) work-school, (4) finances, and (5)

miscellaneous. Results demonstrated that older adults (aged 65 years or older)
worried most about health and least about work, whereas younger adults (aged
25 to 64) worried most about family and finances. The authors reported a linear
relationship between worries and age, noting that worries about family, work,
and finances decreased with age while concerns about health and miscella-
neous issues increased with age (Person & Borkovec, 1995). Thus, common
worries across various age groups appeared to represent changing life circum-
stances.
In another community survey of worries among younger and older adults,
older persons reported few worries overall, with significantly fewer worries
about social events and finances than in a college-age comparison group (Pow-
ers, Wisocki, & Whitbourne, 1992). Elderly participants in this survey worried
most about health, although scores in this domain were similar for older and
younger cohorts. Again, reported fears for both groups appeared to represent de-
velopmentally appropriate real-life concerns. However, it is notable that in this
community sample of older adults, worries occurred infrequently, suggesting
that older age is not necessarily associated with significantly increasing anxiety,
despite the relatively high prevalence rates reviewed above (Powers et aI.,
1992). Similarly, in a broader examination of anxiety characteristics in 94 older
adult volunteers without diagnosable psychiatric symptomatology, scores on a
series of self-report anxiety measures were significantly lower than those re-
ported in younger community samples (Stanley, Beck, & Zebb, 1996). In partic-
ular, older adults demonstrated lower levels of worry, state and trait anxiety,
specific fears, and obsessive-compulsive symptomatology, suggesting that many
older adults are functioning well with regard to various anxiety symptoms. In
addition, these data accentuate the need for age-appropriate norms to interpret
self-report measures of anxiety symptoms in older adults (see the following sec-
tion, "Assessment").
In addition to documenting normal patterns of worry in the elderly, it also
is of interest to examine the psychopathological features associated with vari-
ous anxiety disorders in well-diagnosed clinical samples (Hersen & Van Has-
selt, 1992). One of the first studies in this domain examined the clinical
characteristics of GAD in 44 older adults diagnosed according to a semistruc-
tured interview (Beck et aI., 1996). Comparisons with a matched sample free of
psychiatric disorders were made to assess severity of worry and associated
symptoms. Results revealed that GAD in older persons was associated with el-
evated anxiety, worry, social fears, and depression. Of particular interest is the
fact that elderly GAD patients were comparable with younger samples with
GAD on various demographic variables (e.g., gender, ethnicity, education) and
clinical features (e.g., severity of worry, anxiety, and depression). Similar find-
ings were reported in a retrospective chart review of elderly patients with panic
disorder (Raj et a1., 1993). Although the focus ofthis report was on the overlap
between patients with early- or late-onset disorders, the authors noted that
older adults with panic disorder were similar to younger patients with the same
diagnosis on various demographic and clinical features. Thus, although the
body of literature at present is quite small, anxiety disorders appear to be asso-
ciated with similar psychopathological features across the lifespan.
Overlap With Depression and Medical Problems
Overlap between the anxiety disorders and depression has long been an
important issue in psychiatric diagnosis, with high frequencies of coexisting
pathology and symptom overlap demonstrated repeatedly in younger adult
samples (e.g., Cloninger, 1990; Copp, Schwiderski, & Robinson, 1990; Feldman,
1993). Specifically, 6-month prevalence data from the ECA study indicated that
21 % of participants with an anxiety disorder also met criteria for an affective
disorder, and one third of individuals with affective disorders also were diag-
nosed with an anxiety disorder (Regier et aI., 1990). In recent reviews, signifi-
cant overlap between anxiety and depression in the elderly also has been
highlighted (Alexopoulos, 1991; Flint, 1994). In particular, a community survey
by Lindesay, Briggs, and Murphy (1989) reported that 90.9% of older adults di-
agnosed with GAD and 39.3% of those assigned a diagnosis of phobia also met
criteria for depression. (In this report, ICD-8 diagnoses were assigned based on
a semistructured clinical interview). Not surprisingly, significant correlations
also were noted between measures of anxiety and depression. Finally, in a ret-
rospective chart review of elderly clinic patients with Diagnostic and Statisti-
cal Manual of Mental Disorders, 3rd ed., rev. (DSM-III-R; American Psychiatric
Association, 1987), panic disorder, Raj and colleagues (1993) found that 45%
met criteria for comorbid major depression. When older adults with depressive
disorders have been assessed, more than one third have been assigned a coex-
istent anxiety disorder diagnosis (Alexopoulos, 1991). Even greater percentages
of depressed patients have been reported to experience both psychic and so-
matic symptoms of anxiety (Alexopoulos, 1991; Ben-Aire, Swartz, & Dickman,
1987; Parmelee, Katz, & Lawton, 1992). Thus, although frequency estimates
vary considerably across studies (probably because of differing methodological
procedures), data consistently show a significant amount of overlap between
anxiety and depressive disorders and symptoms in older persons.
As noted earlier, another issue that is highly salient for the evaluation of
anxiety disorders in older adults is the overlap between anxiety symptoms and
the manifestations of various medical diseases. In particular, anxiety-like symp-
toms can be produced by a range of physical conditions including cardiovas-
cular disease, chronic obstructive pulmonary disease, hyperthyroidism, and
sensory impairments involving both the visual and auditory systems (Cohen,
1991). In addition, high rates of anxiety disorders have been reported among el-
derly patients with these types of physical conditions (Cohen, 1991). In fact,
ECA data indicated that anxiety disorders were significantly more prevalent
among older adults who reported being confined to their homes than others
who were more mobile, with statistical effects explained by variations in phys-
ical functioning and not socioeconomic status (Bruce & McNamara, 1992). As
noted, the frequency of significant anxiety symptoms in older adults seen in a
primary care setting has been estimated at 8% to 10% (Oxman et aI., 1987).
Older adults with anxiety disorders or symptoms also report high levels of
physical complaints. For example, Lindesay (1991) found that older adults with
phobic disorders endorsed significantly more physical symptoms than control
participants. Similarly, significant positive correlations have been noted be-
tween severity of anxiety and extent of physical health problems in both com-
munity (Himmelfarb & Murrell, 1984) and nursing home samples (Parmelee et
a1., 1992). Thus, although the amount of available literature is limited, the over-
lap between anxiety problems and medical illness is clearly an important issue
that warrants attention in all psychiatric evaluations among older adults.
ASSESSMENT
Of central importance to any future work addressing the nature and treat-
ment of anxiety disorders in the elderly is the development of psychometrically
sound assessment strategies for this population. In younger adults, a broad
range of assessment instruments has been established to measure anxiety symp-
toms (Nietzel, Bernstein, & Russell, 1988). One popular strategy for assessment
research with older adults has involved examination of psychometric proper-
ties for measures that already have been demonstrated reliable and valid in
younger adults. This strategy has both advantages and disadvantages. First, fur-
ther examination of preexisting measures is economical in terms of time and ex-
pense. In addition, this approach allows for potential comparisons of symptoms
in older and younger samples. However, it also has been noted that the phe-
nomenological experience of anxiety among the elderly may not be well repre-
sented by measures for younger adults (Sheikh, 1991). In particular, assessment
instruments for use with the elderly may need to be particularly sensitive to
certain symptom patterns that are more prevalent in this population (e.g., wor-
ries about health, Person & Borkovec, 1995), as well as potential overlap be-
tween the symptoms of anxiety and medical illness and the comorbidity
between anxiety and depression (Hersen, Van Hasselt, & Goreczny, 1993;
Sheikh, 1991). Given the potentially unique experience of some facets of anxi-
ety in the elderly, another assessment strategy has involved creation of new
measures specifically targeting anxiety symptoms in older adults. These two
strategies have produced a small body of literature addressing the utility of var-
ious anxiety measures for older adults.
Clinician-Rated Instruments
Clinician-rated instruments are used regularly to assist in the diagnosis of

anxiety disorders among younger adults. The most popular diagnostic inter-
view in this regard is the Anxiety Disorders Interview Schedule (ADIS), the
most recent version of which (ADIS-IV; Brown, DiNardo, & Barlow, 1994) was
created to establish anxiety disorder diagnoses according to DSM-IV (American
Psychiatric Association, 1994). Interrater agreement for an earlier version of this
instrument has been well documented in younger adult samples (e.g., DiNardo,
Moras, Barlow, Rapee, & Brown, 1993). Nonetheless, the instrument has been
used only recently to identify anxiety disorders in the elderly. Specifically, in a
set of studies designed by the authors and their colleagues to investigate the na-
ture and treatment of GAD in older adults (Beck, Stanley, & Zebb, 1995; Beck et
a1., 1996; Stanley, Beck, & Glassco, 1996; Stanley, Beck, & Zebb, 1996), the
ADIS-R (DiNardo & Barlow, 1988) was used to establish principal DSM-III-R
diagnoses of GAD and to identify coexistent anxiety and unipolar affective dis-
orders. All ADIS-R interviews in a total sample of 50 GAD patients (aged 55
years and older) were videotaped, with 28% selected randomly for evaluation
by a second clinician to estimate interrater agreement. Diagnostic agreement of
100% was noted for GAD, most likely due to extensive prescreening of poten-
tial participants and the use of videotaped interviews rather than administra-
tion of two separate interviews (Borkovec & Costello, 1993). Kappa coefficients
for coexistent diagnoses indicated excellent reliability (1.00) for social phobia,
simple phobia, and panic disorder, and moderate reliability (.58) for major de-
pression. Thus, although the sample upon which these data were based was
small and somewhat homogeneous with regard to diagnostic picture, the resul-
tant coefficients provide some support for the utility of the ADIS-R as a tool for
diagnosing anxiety disorders in the elderly.
Segal, Hersen, Van Hasselt, Kabacoff and Roth (1993) provided support for
the utility of the Structured Clinical Interview for DSM-III-R (SCm; Spitzer,
Williams, Gibbon, & First, 1988), a more broad-based semistructured interview
for diagnosing Axis I disorders, in older adults. This interview was adminis-
tered to 33 adults, aged 55 years and older, seen through university-affiliated
psychiatric outpatient and residential facilities. All interviews were taped and
reviewed by a second clinician to estimate interrater agreement for diagnostic
categories with base rates above 10%. Kappa coefficients revealed excellent in-
terrater agreement for major depression (.70) and the broad categories of anxi-
ety disorders (.77) and somatoform disorders (1.00). In a follow-up study (Segal,
Kabacoff, Hersen, Van Hasselt, & Ryan, 1995), scm interviews were adminis-
tered to another sample of 40 older adults recruited from the same settings. Re-
sults replicated prior findings of strong interrater agreement (kappa) for major
depression (.79) and the broad categories of anxiety and somatoform disorders
(.73, .84), and also provided support for the interrater agreement on panic dis-
order diagnoses (.80). Thus, the scm also appears to be a useful instrument for
the establishment of anxiety disorders in older adults, although future studies
will need to examine its utility in larger samples with higher base rates of vari-
ous anxiety disorders.
Clinician-rated instruments also are used regularly to evaluate the severity
of anxiety, irrespective of diagnosis, in the younger adult literature. The most
routinely used measure in this domain is the Hamilton Anxiety Rating Scale
(HARS; Hamilton, 1959), a 14-item instrument which measures largely somatic
symptoms of anxiety. Interrater agreement for this instrument in younger adults
is well established, although revisions have been suggested to improve its in-
ternal consistency and discriminant validity (Riskind, Beck, Brown, & Steer,
1987). It has been suggested that overendorsement of somatic symptoms may
pose a problem for use of the HARS with elderly samples (Sheikh, 1991). How-
ever, a recent report (Beck et aI., 1996, August) demonstrated adequate inter-
rater agreement for the HARS in a sample of 44 older adults with GAD (r = .82).
This investigation also presented the first set of normative scores for the HARS
in two older adult samples, one with GAD and one without diagnosable psy-
chiatric complaints, both of which were categorized according to the ADIS-R. It
also is notable that the HARS significantly differentiated these two samples of
older adults, with nearly perfect classification of participants into groups as a
result of a discriminant function analysis. Thus, the HARS appears to be a vi-

able measure for use with older anxious adults, although correlations with the
Hamilton Rating Scale for Depression (Hamilton, 1960) were high (Beck et aI.,
1996, August), and its utility for differentiating anxiety and depression in the
elderly has yet to be investigated.
Self-Report Measures
Self-report measures for the assessment of anxiety in younger adults have

been established to target a wide range of symptom types, including (but not
limited to) generalized anxiety, worry, obsessive-compulsive symptoms, and
specific fears. A small collection of literature has emerged that examines the
utility of some of these instruments in older adults.
To evaluate measures of generalized anxiety in the elderly, data have ad-
dressed the psychometric properties of the Spielberger State-Trait Anxiety In-
ventory (STAI; Spielberger et a1., 1970), the Hopkins Symptom Checklist
(SCL-90; Derogatis et a1., 1973), and the Self-Rating Anxiety Scale (SAS; Zung,
1971). In an initial study, the STAI and the STAI for Children (STAIC; Spiel-
berger, Edwards, Lushene, Montouri, & Platzek, 1973) were administered to 51
older adults, ages 55 to 87 years, who were participating in a mental health
gerontology program (Patterson, O'Sullivan, & Spielberger, 1980). The STAIC
was selected given that its simpler format and vocabulary were thought to be
more appropriate for some elders who had difficulty completing the STAI. Ap-
proximately half of the sample were in day treatment and half were residential
clients. Results revealed significant positive correlations among all STAI and
STAIC subscales, with coefficients ranging from .65 to .82. All STAI and STAIC
scores also correlated positively and significantly with a clinician-rated mea-
sure of anxiety from the Missouri Inpatient Behavioral Scale (MIBS; Sletten &
Ulett, 1972), although the magnitude of these correlations was low (.34 to .44).
Thus, the data provided some evidence for convergent validity of the STAI and
STAIC in older adults. In addition, nonsignificant correlations were noted be-
tween the anxiety measures and other MIBS ratings, indicating support for the
divergent validity of the STAI and STAIC. The authors concluded that these two
instruments could be considered parallel forms in the evaluation of older adults
(Patterson et a1., 1980). As noted by Hersen and Van Hasselt (1992), however,
results of this report are limited by the small and diagnostically heterogeneous
sample, many of whom were heavily medicated and none of whom were cate-
gorized based on semistructured interviews.
In a second study with the STAI, Himmelfarb and Murrell (1983) adminis-
tered the trait subscale to 109 geriatric inpatients and 279 community residents
aged over 55 years. Results provided normative data for both groups and re-
vealed adequate internal consistency in both subsamples (coefficient alpha =
.87, .93, respectively). Significant, positive correlations also were noted be-
tween the STAI-Trait and measures of depression, life satisfaction, well-being,
and affect balance. As expected, the inpatient group had a significantly higher
mean score on the STAI-Trait than the community sample, even when signifi-
cant differences between the groups on age, gender, health status, and marital
status were controlled. However, discriminant analyses indicated that measures

of well-being and depression were the best predictors of group membership,
with no significant additional contribution of trait anxiety. The data thus pro-
vided mixed support for the reliability and validity of the STAI for older adults,
although the inpatient group was diagnostically heterogeneous and no semi-
structured interviews were used to categorize participants.
In a more recent study (Stanley, Beck, & Zebb, 1996), the STAI was admin-
istered to two groups of older adults (aged 55 to 82 years), both of which were
selected based on the ADIS-R. One group (n = 50) met DSM-III-R criteria for
GAD, while the other group (n =94) had no diagnosable psychiatric complaints.
Results revealed adequate internal consistency for the STAI Trait and State sub-
scales in both groups (alpha = .79 to .84). Test-retest reliability, assessed over a
2- to 4-week interval in a subgroup of 46 control participants, was strong for the
STAI-Trait subscale (r = .84), but weaker for the State subscale (r = .62), as
would be expected. Evidence for convergent validity in the normal control
group was strong, as demonstrated by significant correlations with measures of
worry, obsessive-compulsive symptoms, and specific fears. However, conver-
gent validity in the patient group was mixed, possibly demonstrating some de-
gree of independence among these symptom types in patients with GAD. In a
separate analysis of data from the same study, Beck et al. (1996) demonstrated
significant differences between STAI scores for older adults with GAD and a
matched group of normal controls. Discriminant analyses revealed, however,
that the STAI did not contribute significantly to the prediction of group mem-
bership.
Other measures of general anxiety that are used regularly with younger
adults have been examined in a preliminary fashion with elderly samples. For
example, Magni and DeLeo (1984) administered the SCL-90 anxiety and de-
pression scales to 178 elderly hospital patients. The data provided normative
scores for the sample and indicated that older adults reported fewer anxiety
symptoms than a comparison group of younger adult hospital patients. Results
failed to demonstrate a significant relationship between anxiety and type of
medical illness in either sample. Although these data provided some informa-
tion regarding the evaluation and nature of anxiety in older adults, as Hersen
and Van Hasselt (1992) noted, the study failed to address the utility of the SCL-
90 in older psychiatric patients. In another report, Zung (1980) administered
the SAS to a normal sample of 91 adults aged 65 and over. Descriptive data re-
vealed a mean score similar to that for younger adults (aged 20 to 64). However,
no other psychometric or demographic data were provided in this report.
In addition to data regarding measures of general anxiety, other studies
have begun to examine the psychometric properties of self-report instruments
that assess more specific types of anxiety symptoms in older samples. Again,
available data have addressed the utility of measures developed for younger
samples. In particular, the psychometric properties of the Penn State Worry
Questionnaire (PSWQ; Meyer, Miller, Metzger, & Borkovec, 1990), the Padua In-
ventory (PI; Sanavio, 1988), and the Fear Questionnaire (FQ; Marks & Mathews,
1979) have been examined in samples of older adults (aged 55 to 82) with GAD
or no diagnosable psychiatric symptomatology based on the ADIS-R (Beck et
al., 1995; Stanley, Beck, & Zebb, 1996). The PSWQ is a 16-item scale designed
to assess a person's tendency to worry. without focus on specific content of the

worry. The PI is a 60-item questionnaire that evaluates obsessive-compulsive
symptoms. with subscales assessing the severity of contamination and checking
rituals. as well as fears of losing control over mental activities and motor be-
haviors. The FQ is a well-known 15-item inventory assessing severity of avoid-
ance related to agoraphobic. social. and blood-injury fears.
In both the GAD and normal control samples. the PSWQ demonstrated
strong internal consistency (coefficient alpha> .80; Beck et al., 1995). Adequate
convergent validity for this instrument also was demonstrated by significant
correlations with other measures of anxiety and depression (Beck et al., 1995).
In addition. factor analyses suggested a two-factor structure for the PSWQ in
both groups. with items loading on the first factor appearing to assess a ten-
dency to worry and items on the second factor assessing an absence of worry.
However. it should be noted that internal consistency for the second factor in
the GAD group was marginal (alpha =.60). In a separate analysis, scores on the
PSWQ were significantly different in the GAD sample and a matched normal
control group. and this measure had a very high positive loading in a discrimi-
nant function analysis that successfully separated these two subsamples (Beck
et al., 1996).
Internal consistency of the PI generally was adequate in both samples (al-
pha = .74 to .95), with the exception of the Behavior Control subscale in the nor-
mal control group (alpha = .19), wherein a restricted range of scores may have
created subscale instability (Stanley. Beck, & Zebb. 1996). Internal consistency
for the FQ Total and Bodily Injury subscales were adequate in both groups (al-
pha = .73 to .85), although alpha coefficients for the FQ Social Phobia sub scale
in both samples and the Agoraphobia subscale in the GAD group were marginal
(.60 to .67). Coefficients of test-retest reliability, assessed in a subsample of nor-
mal control participants over a 2- to 4-week interval, suggested that the Total
and some subscale scores of the PI assessed stable, traitlike features while other
subscales estimated more statelike clinical symptoms (r = .61 to .80). Stability
over time for the FQ in general was poor (r = .41 to .64). with post hoc compar-
isons revealing a pattern of decreasing fear over the test-retest interval. indi-
cating the possibility of regression to the mean on this measure for older adults
without anxiety complaints. Adequate convergent validity was demonstrated
for the PI. with significant correlations between this instrument and other mea-
sures of worry and anxiety in both the GAD and normal control groups. The FQ.
however, failed to correlate significantly with other measures of anxiety symp-
toms in the GAD group. possibly due to potential reliability problems with this
instrument in older adults.
In general, available data suggest that the STAI, PSWQ. and PI, which have
been used routinely in samples of younger adults. also should be useful for fur-
ther investigations of psychopathology and treatment in samples of older anx-
ious adults. Additional data are needed. however. to address the utility of these
measures for discriminating older adults with GAD from those with other anx-
iety disorders (e.g .• panic disorder. specific phobias). alternative psychiatric
syndromes (e.g .• depression). or serious medical conditions. In addition. given
mixed reliability data for the FQ, further consideration should be given to the
measurement of specific fears in older adults (Stanley. Beck. & Zebb. 1996).
As an alternative to addressing the utility of instruments previously used

in younger adults, another psychometric strategy involves the development of
new measures specifically targeting anxiety symptoms in the elderly. Wisocki
and her colleagues have developed the Worry Scale (WS; Wisocki, Handen, &
Morse, 1986), a 35-item self-report measure that targets financial, health, and
social worries commonly associated with aging. Preliminary reports provided
some support for the concurrent validity of the WS in community-dwelling and
homebound older adults (Powers et al., 1992; Wisocki et al., 1986; Wisocki,
1988). In a study previously described (Stanley, Beck, & Zebb, 1996), additional
psychometric data were collected for the WS in two samples of older adults
with GAD or no diagnosable psychiatric symptomatology. Coefficients of inter-
nal consistency were adequate in both groups (alpha = .76 to 94). Two- to
4-week test-retest reliability, assessed in a subsample of normal control partic-
ipants, also was adequate (r = .69 to .80), with the exception of the Health sub-
scale (r = .58). It was suggested that this subscale may have assessed sensitivity
to real physical complaints which varied over time for nonanxious older adults,
whereas financial and social issues remained more stable for individuals in this
group. Adequate convergent validity for the WS also was demonstrated in both
groups, with significant correlations between this measure and instruments as-
sessing obsessive-compulsive symptoms and general anxiety (Stanley, Beck, &
Zebb, 1996). In a separate analysis of an overlapping dataset (Beck et al., 1996),
WS scores were significantly different in the GAD sample and a matched nor-
mal control group, and the Social Phobia subscale was one of four variables that
successfully differentiated these groups in a discriminant function analysis.
Thus, the WS also appears useful for future investigations of the nature and
treatment of anxiety in older adult samples, although again, further work is
needed to examine the utility of this instrument for discriminating older anx-
ious adults from those with other psychiatric disorders or significant medical
problems.
TREATMENT
Utilization of Services
Despite relatively high prevalence rates of anxiety disorders among older

persons and the severity of interference in life function that may result, very few
older adults with anxiety problems seek assistance from mental health profes-
sionals. In particular, ECA data indicated that only 0.6% of adults over age 65
with agoraphobia and 2.2% with other phobias had sought services from a men-
tal health provider in the 6 months prior to interview (Thompson et aI., 1988).
A greater percentage of older adults in these groups had sought assistance for
mental health problems from alternative sources (e.g., general physicians,
clergy), but even across these settings, older adults with agoraphobia were sig-
nificantly less likely to have sought treatment of any type for emotional prob-
lems than were adults aged 25 to 64 (Thompson et aI., 1988). Similarly, Lindesay
(1991) reported that only 3% of older adults classified with phobias had ever re-
ceived any form of treatment specifically for their phobic symptoms. Finally,
Blazer et a1. (1991) noted that only 38% of older adults with GAD (identified
during Wave II of the ECA survey) reported utilization of outpatient mental
health services during the year prior to interview. Thus, it is clear that only a mi-
nority of older adults with anxiety disorders seek and utilize available mental
health services. This pattern is consistent with reports that mental health re-
sources in general are severely underutilized by the elderly (Lasoski, 1986).
Explanations for these patterns of underutilization have included the re-
luctance of older adults to define their difficulties in psychological terms or to
seek social services of any kind, the relative lack of treatment providers avail-
able to offer services to this population, and practical barriers including trans-
portation problems, financial difficulties, and limited outreach or publicity for
services (Lasoski, 1986; McCarthy, Katz, & Foa, 1991). Also, as mentioned pre-
viously, it often is tempting for older adults and mental health providers to at-
tribute the signs and symptoms of anxiety to a normal aging process, thereby
overlooking treatable psychiatric disorders (Weiss, 1994). As a result of these
factors, the empirical literature addressing the efficacy of treatments for anxiety
in older people is quite limited. Nonetheless, there appears to be some support
for the utility of both pharmacological and cognitive-behavioral interventions.
Pharmacological Treatment
Treatment of anxiety in older adults typically begins in a primary medical

care setting (Blazer et a1., 1991; McCarthy et a1., 1991) and most often involves
the use of antianxiety medication, typically the benzodiazepines. In fact, older
adults report more frequent use of these medications than younger samples
(Blazer et a1., 1991), with figures from 17% to 50% reported (Salzman, 1991).
Despite such widespread use, literature addressing the efficacy of benzodi-
azepines in older adults is limited in terms of both number of studies available
and methodological rigor. In a review of 14 studies ofbenzodiazepine treatment
for anxiety in older adults, Salzman (1991) noted some evidence for the efficacy
of chlordiazepoxide, diazepam, lorazepam, and oxazepam. Other data have at-
tested to the effects of alprazolam relative to placebo (Cohn, 1984). However,
conclusions from these studies are seriously limited by methodological prob-
lems including the use of diagnostically heterogeneous samples selected via un-
structured clinical interviews, failure to differentiate participants with primary
anxiety symptoms from those with anxiety secondary to depression or medical
disease, failure to distinguish anxiety disorders from behavioral agitation re-
sulting from dementia or psychosis, omission of appropriate controls for med-
ical illnesses or concomitant drug treatment, and variations in outcome criteria
and treatment duration (Salzman, 1991).
Despite these serious limitations, recommendations regarding the use of
benzodiazepines in the elderly have been made routinely (Fernandez, Levy,
Lachar, & Small, 1995; Markovitz, 1993; Weiss, 1994), generally on the basis of
studies addressing the use of anxiolytics in younger adults, pharmacokinetic
properties of the medications in nonsymptomatic elderly, and anxiolytic toxic-
ity in older adults (Salzman, 1991). Recommendations have been consistent,
suggesting that short half-life benzodiazepines be used for as brief a duration
as possible, with some authors noting the need to consider psychosocial inter-
ventions whenever appropriate (Lader, 1986; Wengel, Burke, Ranno, & Roc-
caforte, 1993). Recommended benzodiazepine doses for the elderly are lower
than those prescribed for younger adults given age-related alterations in the ab-
sorption, distribution, metabolism, and elimination of these medications that
lead to increased sensitivity to therapeutic effects and adverse events (Lader,
1986). Because of these pharmacokinetic changes, significant attention has been
given to concerns regarding cognitive impairment, respiratory depression, and
psychomotor slowing that may be associated with benzodiazepine use in the el-
derly (Weiss, 1994; Wengel et a!., 1993). In particular, it has been noted that use
of benzodiazepines may create amnesia, delayed recall, confusion, disorienta-
tion, and agitation among older adults, and that psychomotor slowing or overse-
dation may lead to increased rates of falls and hip fractures (Wengel et a1.,
1993). These symptoms in turn also may exacerbate anxiety symptoms (in par-
ticular, worry). Other pharmacotherapy-related concerns include potential drug
interactions, given increased rates of medical illness among older adults, and
medication compliance. Survey data have pointed to an increased risk of alter-
ations in medication doses or schedules when more than three drugs are pre-
scribed per day (Salzman, 1995). Given that 25% of elders are prescribed
multiple (3 or more) medications, compliance problems are of central impor-
tance in the pharmacological treatment of anxiety among older adults.
Although benzodiazepines remain the most frequently prescribed drugs for
anxiety among older adults, pharmacological recommendations also include
consideration of other types of medications. The greatest amount of attention
has been given to the effects of buspirone. At least four open trials have docu-
mented the utility of this medication for the treatment of anxiety among older
persons (Salzman, 1991). Clinical recommendations generally have noted that
the therapeutic effects of bus pirone are comparable to those of the benzodi-
azepines, although side effects are preferable for buspirone given its negligible
potential for tolerance, withdrawal, or serious overdose toxicity (Weiss, 1994).
However, due to the lack of well-controlled treatment trials comparing the ef-
fects of bus pirone to placebo or benziodiazepines among the elderly, these rec-
ommendations are without strong empirical support.
Clinical recommendations based on empirical studies with younger adults
also have noted the potential efficacy of beta blockers and antidepressants for the
treatment of anxiety in older adults, and the possible utility of antihistamines
has been mentioned (Fernandez et a!., 1995; Markovitz, 1993). Given that no em-
pirical support for these medications in older adults has been reported, these
recommendations must be considered very carefully. In general, the dearth of
data addressing the pharmacological treatment of anxiety disorders among the
elderly suggests that significant work is yet to be done in this domain to estab-
lish standards of treatment for the different anxiety disorders in this population.
Cognitive Behavioral Treatments
Although treatment with medication may be effective for reducing anxiety,

chronic and widespread use of benzodiazepines in this population may not be
optimal treatment given the potential problems noted earlier. Furthermore, a
pharmacological approach to treatment typically neglects potentially important
psychosocial factors such as social support, coping skills, and interpersonal re-
lationships. Thus, the development of psychosocial adjuncts or alternatives for
the treatment of anxiety in older persons is highly desirable. Although a signif-
icant number of studies have addressed the utility of psychosocial interven-
tions for the treatment of depression in older adults (e.g., Arean et a1., 1993;
Thompson, Gallagher, & Breckenridge, 1987), relatively little attention has been
paid to the development of psychosocial treatments for anxiety disorders in this
population. Given the well-developed literature supporting the utility of cog-
nitive behavior therapy (CBT) for anxiety among younger adults (e.g., Barlow,
1988; Beidel & Turner, 1991), it is not surprising that initial efforts to identify ef-
fective psychosocial treatments in older samples have concentrated on these
approaches. However, the majority of literature currently available is limited
to clinical case studies or group comparisons with nonclinical volunteers who
report general anxiety complaints.
Case studies have addressed the utility of cognitive-behavioral interventions
with elderly adults who meet diagnostic criteria for generalized anxiety disorder
(King & Barrowclough, 1991), panic disorder (Rathus & Sanderson, 1994), spe-
cific phobias (Thyer, 1981), and obseSSive-compulsive disorder (Calamari, Faber,
Hitsman, & Poppe, 1994; Carmin, Ownby, & Pollard, 1995; ]unjinger & Ditto,
1984). Treatment approaches have followed closely those validated empirically
in younger samples, with results documenting the utility of various forms of ex-
posure, response prevention, breathing retraining, and cognitive restructuring.
Conclusions from these case reports are limited, of course, by the lack of appro-
priate methodological controls. Nonetheless, these types of reports provide some
support for the benefits of further empirical investigation into the usefulness of
cognitive behavioral treatments for anxiety in older persons.
A number of controlled group comparisons with nonclinical volunteers re-
porting anxiety complaints have provided additional support for the potential
use of CBT with older adults. In one of the earliest of these studies, 36 female
volunteers (aged 63 to 79) with complaints of anxiousness, tension, fatigue, in-
somnia, sadness, and somatic symptoms were assigned randomly to receive one
of two versions of relaxation training or an attention control condition (DeBerry,
1982). Participants were selected from a prescreening procedure that followed
a discussion about stress at a senior citizen center. Results demonstrated that re-
laxation training led to significant decreases in state and trait anxiety on the
STAI, although no changes were noted in the control condition. On the other
hand, depressive symptoms (measured by the Zung depression scale) were not
diminished in any group.
In a similar comparison, 24 community volunteers (aged 60 years and
older) with both anxiety and depressive symptoms were selected from atten-
dants at a series of self-improvement workshops (Sallis, Lichstein, Clarkson,
Stalgaitis, & Campbell, 1983). Participants were assigned randomly to receive
behavioral treatment for anxiety (relaxation training)' cognitive behavioral
treatment for depression (pleasant events scheduling and rational emotive pro-
cedures), or a nonspecific control condition that involved self-disclosure and
reflection of feelings. Results revealed significant improvement in both anxiety
and depression, as measured by the STAI and the Beck Depression Inventory
(BDI), for participants in all groups.
Subsequently, DeBerry and colleagues (DeBerry, Davis, & Reinhard, 1989)

compared the effects of relaxation training, cognitive restructuring, and an at-
tention control condition in 32 nonclinical volunteers (aged 65 to 70 years)
with various anxiety-related complaints. Results indicated that only relaxation
training was effective in decreasing STAI state anxiety scores, although STAI
trait anxiety and BDI scores were improved across all conditions. More recently,
progressive and imaginal relaxation training were compared with a wait-list
control group in 71 older adults (aged 60 years and older) with subjective ten-
sion or anxiety or both (Scogin, Rickard, Keith, Wilson, & McElreath, 1992). Re-
sults revealed significantly greater decreases in anxiety, as measured by the
STAI state anxiety scale and the SCL-90-R, following both types of relaxation
training relative to the control condition. Treatment gains also were maintained
at 1-year follow-up (Rickard, Scogin, & Keith, 1994).
Taken together, these studies suggest some efficacy of cognitive behavioral
interventions, in particular relaxation training, for the treatment of anxiety in
older adults. However, results are limited by small sample sizes and the focus
on nondiagnosed community volunteers. Only recently has a group comparison
study addressed the utility of cognitive behavioral interventions for a sample of
older adults diagnosed via semistructured clinical interview.
Following findings from the younger adult literature, Stanley, Beck, and
Glassco (1996) conducted a comparison of CBT and nondirective supportive
psychotherapy (SP) in a sample of 48 older adults with generalized anxiety dis-
order (GAD). Participants were recruited through the community and diag-
nosed according to the ADIS-R. CBT and SP were conducted in a small group
format, with weekly meetings over a 14-week period. CBT included three major
components: progressive deep muscle relaxation (sessions 1 through 5), cogni-
tive therapy (session 6 through 10), and exposure treatment (sessions 11
through 14). SP focused on nondirective group discussion of anxiety symptoms
and experiences, with the therapist assuming a supportive, facilitative role. Re-
sults indicated significant pre-to-post decreases in measures of worry (e.g.,
PSWQ, global severity of GAD, time spent worrying), anxiety (STAI, HARS),
and depression (BDI, HRSD) for participants in both treatment groups. Some ev-
idence for a preferential effect of CBT on measures of specific fears (FQ) was
noted, although potential problems with the psychometric properties of the FQ
limit this conclusion. Six-month follow-up analyses revealed maintenance of
treatment gains on measures of anxiety and depression, with some continued
improvement in severity of worry for both groups. Correlational analyses fur-
ther suggested that pretreatment severity of anxiety and ratings of treatment
credibility (provided after treatment procedures had been explained) correlated
significantly with outcome. In particular, higher levels of pretreatment anxiety
and lower estimates of treatment credibility were associated with poorer re-
sponse at posttreatment. Conclusions from this study are limited by the omis-
sion of a no-treatment or wait-list control condition. However, this study is the
first to document the potential viability of psychosocial treatment procedures
for older adults with well-diagnosed anxiety disorders. Future studies will need
to include appropriate control conditions and assess the effects of cognitive be-
havioral and other psychosocial interventions for older adults with GAD and
other DSM-IVanxiety disorders.
SUMMARY
Anxiety disorders are the most prevalent of all psychiatric conditions

among the elderly, with phobias and generalized anxiety disorder the most
commonly assigned diagnoses. Current prevalence estimates, along with the
degree of interference in life function that can result from significant anxiety
problems, suggest that these disorders pose a serious public health problem for
older adults. Additional epidemiological data are needed, however, regarding
the ethnic distribution of anxiety disorders among the elderly. More informa-
tion also is needed to address issues of differential diagnosis in this popula-
tion, with specific attention to the overlap between anxiety, depression, and
medical illness, as well as the distinction between anxiety disorders and
symptoms of anxiety that may be associated with the normal aging process. In
this regard, the need for age-appropriate norms for standardized assessment
tools is paramount.
With regard to psychopathology, recent studies have begun to identify fea-
tures of anxiety disorders in the elderly that suggest overlap with younger adult
samples as well as those characteristics of anxiety that may be unique to older
individuals. To date, the majority of this work has focused on worry and associ-
ated symptoms. However, more attention will need to be given to these issues in
elderly patients with a range of anxiety disorders. To do so, further research will
need to address the development of appropriate and psychometrically sound as-
sessment tools. One strategy has involved examination of the psychometric char-
acteristics of instruments commonly used with younger adults. Some support
has been obtained for the reliability and validity of both self-report and clini-
cian-rated measures of worry, anxiety, and obsessive-compulsive symptoms.
Given the potentially unique experience of some facets of anxiety in the elderly,
another assessment strategy has involved creation of new measures specifically
targeting anxiety symptoms in older adults. This approach has yielded one mea-
sure of worry that appears useful for future investigations. More data are needed,
however, to establish a broad range of measures that can be used routinely for
evaluation of elderly samples in both research and clinical settings. Normative
data with both community and clinical samples will be needed, with study par-
ticipants classified carefully according to structured interview procedures
(Hersen & Van Hasselt, 1992).
With the establishment of psychometrically sound assessment procedures,
it should be possible to extend the treatment literature dramatically. At present,
studies regarding the effects of pharmacological and psychosocial (primarily
cognitive behavioral) interventions are severely limited by the omission of ap-
propriate control groups and the use of diagnostically heterogenous clinical
groups or samples of nonclinical community volunteers with vague anxiety
complaints. Future studies will need to be conducted with samples of carefully
diagnosed participants who are assigned randomly to the treatments of interest
and appropriate control conditions. Emphasis will need to be placed on the ef-
fects of treatment not only on symptom reduction, but also on the transfer ef-
fects of interventions on associated depression, social functioning, and quality
of life. Durability of treatment response over long-term follow-up intervals also
will need to be targeted, as will generalizability of findings to patients recruited

from a wide array of settings (e.g., psychiatric clinics, primary care facilities)
and from diverse sociocultural backgrounds.
REFERENCES
Alexopoulos, G. s. (1991). Anxiety and depression in the elderly. In C. Salzman & B. D. Lebowitz
(Eds.), Anxiety in the elderly: Treatment and research (pp. 63-77). New York: Springer.
(3rd ed.). Washington, DC: Author.
(3rd ed.-revised). Washington, DC: Author.
Arean, P. A., Perri, MG., Nezu, A. M., Schein, R. L., Christopher, E, & Joseph, T. X. (1993). Compar-
ative effectiveness of social problem-solving therapy and resminiscence therapy as treatments
for depression in older adults. Journal of Consulting and Clinical Psychology. 61, 1003-1010.
Barlow, D. H. (1988) Anxiety and its disorders. New York: Guilford.
Beck, J. G., Stanley, M. A., & Zebb. B. J. (1995). Psychometric properties of the Penn State Worry
Questionnaire in older adults. Journal of Clinical Geropsychology. 1. 33-42.
Beck. J. G.• Stanley. M. A.• & Zebb. B. J. (1996). Characteristics of generalized anxiety disorder in
older adults: A descriptive study. Behavior Research and Therapy. 34. 225-234.
Beck. J. G.. Stanley. M. A.. & Zebb, B. J. (1996. August). How do the Hamiltion scales perform with
geriatric GAD patients? Paper presented at the Annual Convention of the American Psycho-
logical Association. Toronto, Ontario.
Beidel, D. C.• & Thrner. S. M. (1991). Anxiety disorders. In M. Hersen & S. M. Thrner (Eds.). Adult
psychopathology and diagnosis (pp. 226-278). New York: Wiley.
Ben-Arie. 0., Swartz. L., & Dickman. B. J. (1987). Depression in the elderly living in the community:
Its presentation and features. British Journal of Psychiatry. 150, 169-174.
Blazer. D.• George, L. K.• & Hughes. D. (1991). The epidemiology of anxiety disorders: An age com-
parison In C. Salzman & B. D. Lebowitz (Eds.), Anxiety in the elderly: Treatment and research
(pp. 17-30). New York: Springer.
Borkovec. T. D., & Costello. E. (1993). Efficacy of applied relaxation and cognitive-behavioral ther-
apy in the treatment of generalized anxiety disorder. Journal of Consulting and Clinical Psy-
chology. 61,611-619.
Brown. T. A., DiNardo. P. A.. & Barlow, D. H. (1994). Anxiety Disorders Interview Schedule for DSM-
Iv. Albany, NY: Phobia and Anxiety Disorders Clinic. Center for Stress and Anxiety, State Uni-
versity of New York.
Bruce. M. L., & McNamara. R. (1992). Psychiatric status among the homebound elderly: An epi-
demiologic perspective. Journal of the American Geriatrics Society. 40. 561-566.
Calamari, J. E.. Faber, S. D.. Hitsman. B. L., & Poppe. C. J. (1994). Treatment of obsessive compulsive
disorder in the elderly: A review and case example. Journal of Behavior Therapy and Experi-
mental Psychiatry. 25. 95-104.
Carmin, C. N.. Ownby. R. L.• & Pollard. C. A. (1995. November). Effects of cognitive behavioral treat-
ment of obsessive compulsive disorder in geriatric versus younger adult patients. Paper pre-
sented at the annual convention of the Association for Advancement of Behavior Therapy,
Washington. DC.
Carstensen. L. L. (1988). The emerging field of behavioral gerontology. Behavior Therapy. 19.
259-281.
Cloninger. C. R. (1990). Comorbidity of anxiety disorders. Journal of Psychopharmacology. 1D. 43-46.
Cohen. G. D (1991). Anxiety and general medical disorders In C. Salzman & B. D. Lebowitz (Eds.).
Anxiety in the elderly: Treatment and research (pp. 47-62). New York: Springer.
Cohn. J. B. (1984). Double-blind safety and efficacy comparison of alprazolam and placebo in the
treatment of anxiety in geriatric patients. Current Therapeutic Research. 35. 100-112.
Copp, J. E., Schwiderski, U. E., & Robinson, D. S. (1990). Symptom comorbidity in anxiety and de-
pressive disorders. Journal of Clinical Psychopharmacology, 10, 52-60.
DeBerry, S. (1982). The effects of meditation-relaxation on anxiety and depression in a geriatric
population. Psychotherapy: Theory. research, and practice, 19, 512-521.
DeBerry, S., Davis, S., & Reinhard, K. E. (1989). A comparison of meditation-relaxation and cogni-
tive behavioral techniques for reducing anxiety and depression in a geriatric population. Jour-
nal of Geriatric Psychiatry, 22, 231-247.
Derogatis. L. R., Lipman, R. S., Rickels, K., Uhlenhuth, E. H., & Covi, L. (1973). The Hopkins Symp-
tom Checklist (HSCL): A self-report inventory. Behavioral Science 19, 1-15.
DiNardo, P. A., & Barlow, D. H. (1988). Anxiety Disorders Interview Schedule-Revised (ADIS-R). Al-
bany, NY: Phobia and Anxiety Disorders Clinic, State University of New York.
DiNardo, P. A., Moras, K.. Barlow, D. H., Rapee, R. M., & Brown, T. A. (1993). Reliability of DSM-
II1-R anxiety disorder categories: Using the Anxiety Disorders Interview Schedule-Revised
(ADIS-R). Archives of General Psychiatry, 50, 251-256.
Eaton, W. W., Kramer, M., Anthony. J. C., Dryman, A., Shapiro, S., & Locke, B. Z. (1989). The inci-
dence of specific DIS/DSM-II1 mental disorders: Data from the NIMH Epidemiologic Catch-
ment Area Program. Acta Psychiatrica Scandinavia. 79, 163-178.
Feinson, M. C.• & Thoits, P. A. (1986). The distribution of distress among elders. Journal of Geron-
tology. 41, 225-233.
Feldman, L. A. (1993). Distinguishing depression and anxiety in self-report: Evidence from confir-
matory factor analysis on nonclinical and clinical samples. Journal of Consulting and Clinical
Psychology. 61. 631-638.
Fernandez, F., Levy, J. K., Lachar, B. L., & Small. G. W. (1995). The management of depression and
anxiety in the elderly. Journal of Clinical Psychiatry. 56, 20-29.
Flint. A. J. (1994). Epidemiology and comorbidity of anxiety disorders in the elderly. American
Journal of Psychiatry. 151.640-649.
Gurian, B. S .• & Miner. J. H. (1991). Clinical presentation of anxiety in the elderly. In C. Salzman &
B. D. Lebowitz (Eds.). Anxiety in the elderly: Treatment and research (pp. 31-44). New York:
Springer.
Hamilton. M. (1959). The assessment of anxiety states by rating. British Journal of Medical Psy-
chology. 32, 50-55.
Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery. and Psy-
chiatry. 23, 56-62.
Helzer. J. E.. Robins. 1. N.• & McEvoy. L. (1987). Post-traumatic stress disorder in the general popu-
lation. New England Journal of Medicine. 317, 1630-1634.
Hersen. M .• & Van Hasselt, V. B. (1992). Behavioral assessment and treatment of anxiety in the el-
derly. Clinical Psychology Review, 12,619-640.
Hersen, M., Van Hasselt, V. B., & Goreczny. A. J. (1993). Behavioral assessment of anxiety in older
adults. Behavior Modification, 17. 99-112.
Himmelfarb, S .. & Murrell. S. A. (1983). Reliability and validity of five mental health scales in older
persons. Journal of Gerontology. 38. 333-339.
Himmelfarb. S .• & Murrell. S. A. (1984). The prevalence and correlates of anxiety symptoms in older
adults. Journal of Psychology, 116,159-167.
Junjinger. J.• & Ditto, B. (1984). Multitreatment of obsessive-compulsive checking in a geriatric pa-
tient. Behavior Modification, 8. 379-390.
King. P.• & Barrowclough, C. (1991). A clinical pilot study of cognitive-behavioral therapy for anxi-
ety disorders in the elderly. Behavioural Psychotherapy, 19.337-345.
Lader. M. (1986). The use of hypnotics and anxiolytics in the elderly. International Clinical Psy-
chopharmacology, 1. 273-283.
Lasoski. M. C. (1986). Reasons for low utilization of mental health services by the elderly. In T. 1.
Brink (Ed.), Clinical gerontology: A guide to assessment and intervention (pp. 1-18). New
York: Haworth.
Liddell. A.• Locker. D.• & Burman, D. (1991). Self-reported fears (FSS-ll) of subjects aged 50 years
and over. Behavior Research and Therapy, 29. 105-112.
Lindesay. J., (1991). Phobic disorders in the elderly. British Journal of Psychiatry, 159, 531-541.
Lindesay, J., Briggs, K, & Murphy, E. (1989). The Guy's/ Age Concern Survey: Prevalence rates of
cognitive impairment, depression and anxiety in an urban elderly community. British Jour-
nal of Psychiatry, 155,317-329.
MagnL G, & De Leo, D. (1984). Anxiety and depression in geriatric and adult medical inpatients: A
comparison. Psychological Reports, 55. 607-612.
Markovitz, P. J. (1993). Treatment of anxiety in the elderly. Journal of Clinical Psychiatry, 54, 64-68.
Marks, I. M., & Mathews, A. M. (1979). Brief standardized self-rating for phobic patients. Behavior
Research and Therapy, 17, 263-267.
McCarthy, P. R, Katz, I. R, & Foa, E. B. (1991). Cognitive-behavioral treatment of anxiety in the el-
derly: A proposed model. In C. Salzman & B. D. Lebowitz (Eds.), Anxiety in the elderly: Treat-
ment and research (pp. 197-214). New York: Springer.
McNally, R J. (1994). Panic disorder: A critical analysis. New York: Guilford.
Meyer, T. J., Miller, M. 1., Metzger, R -1., & Borkovec, T. D. (1990). Development and validation of
the Penn State Worry Questionnaire. Behavior Research and Therapy, 28, 487-495.
Nietzel, M. T., Bernstein, D. A., & Russell, R 1. (1988). Assessment of anxiety and fear. In A. S. Bel-
lack & M. Hersen (Eds.), Behavioral assessment: A practical handbook (3rd ed., pp. 280-312).
New York: Pergamon.
Oxman, T. E., Barrett, J. E., Barrett, J., & Gerber, P. (1987). Psychiatric symptoms in the elderly in a
primary care practice. General Hospital Psychiatry, 9, 167-173.
Parmelee, P. A., Katz, I. R, & Lawton, M. P. (1992). Anxiety and its association with depression
among institutionalized elderly. American Journal of Geriatric Psychiatry, 1, 46-58.
Patterson, R L., O'Sullivan, M. J., & Spielberger. C. D. (1980). Measurement of state and trait anxi-
ety in elderly mental health clients. Journal of Behavioral Assessment, 2, 89-97.
Person, D. C., & Borkovec, T. D. (1995, August). Anxiety disorders among the elderly: Patterns and
issues. Paper presented at the 103rd annual meeting of the American Psychological Associa-
tion. New York.
Powers, C. B., WisockL P. A., & Whitbourne, S. K (1992). Age differences and correlates of worry-
ing in young and elderly adults. Gerontologist, 32, 82-88.
Raj, B. A., Corvea, M. H., & Dagon, E. M. (1993). The clinical characteristics of panic disorder in
the elderly: A retrospective study. Journal of Clinical Psychiatry, 54, 150-155.
Rapee, R M., & Barlow, D. H. (1991). Chronic anxiety: Generalized anxiety disorder and mixed anx-
iety-depression. New York: Guilford.
Rathus, J. H., & Sanderson, W. C. (1994, November). Cognitive behavioral treatment for panic dis-
order in geriatric patients. Paper presented at the annual convention for the Association for
Advancement of Behavior Therapy, San Diego.
Regier, D. A., Boyd, J. H., Burke. I. D., Rae, D. S., Myers, J. K, Kramer, M., Robins, 1. N., George,
1. K, Karno, M., & Locke, B. Z. (1988). One-month prevalence of mental disorders in the
United States: Based on five epidemiologic catchment area sites. Archives of General Psychi-
atry, 45, 977-986.
Regier, D. A., Narrow, W. E., & Rae, D. S. (1990). The epidemiology of anxiety disorders: The Epi-
demiologic Catchment Area (ECA) experience. Journal of Psychiatric Research, 24, 3-14.
Reynolds, C. F., Lebowitz, B. D., & Schneider, L S (1993). Diagnosis and treatment of depression in
late life. Psychopharmacology Bulletin, 29, 83-85.
Rickard, H. c., Scogin, F., & Keith. S. (1994). A one-year follow-up of relaxation training for elders
with subjective anxiety. Gerontologist, 34, 121-122.
Riskind, J. H., Beck, A. T., Brown, G., & Steer, R (1987). Taking the measure of anxiety and depres-
sion: Validity of the reconstructed Hamilton Scales. Journal of Nervous and Mental Disease,
175,474-479.
Robins,1. N., Helzer, J. E., Weissman, M. M., Orvaschel, H., Gruenberg, E., Burke, J. D., & Regier,
D. A. (1984). Lifetime prevalence of specific psychiatric disorders in three sites. Archives of
General Psychiatry, 41, 949-958.
Sailis, J. F., Lichstein, K 1., Clarkson, A. D., Stalgaitis, S., & Campbell, M. (1983). Anxiety and de-
pression management for the elderly. International Journal of Behavioral Geriatrics, 1,3-12.
Sanavio, E. (1988). Obsessions and compulsions: The Padua Inventory. Behavior Research and
Therapy, 26,169-177.
Salzman. C. (1991). Pharmacologic treatment of the anxious elderly patient. In C. Salzman & B. D.
Lebowitz (Eds.). Anxiety in the elderly: Treatment and research. New York: Springer.
Salzman. C. (1995). Medication compliance in the elderly. Journal of Clinical Psychiatry. 56. 18-22.
Salzman. C.• & Lebowitz. B. D. (1991). Anxiety in the elderly: Treatment and research. New York:
Springer.
Scogin. F.• Rickard. H. C.• Keith. S.• Wilson. Joo & McElreath. L. (1992). Progressive and imaginal re-
laxation training for elderly persons with subjective anxiety. Psychology and Aging, 7,
419-424.
Segal, D. L., Hersen. M.• Van Hasselt. V. B.• KabacoffR. I., & Roth. L. (1993). Reliability of diagnosis
in older psychiatric patients using the Structured Clinical Interview for DSM-ID-R. Journal of
Psychopathology and Behavioral Assessment, 15, 347-356.
Segal. D. L.• Kabacoff. R. I.. Hersen. M.• Van Hasselt. V. B.• & Ryan, C. F. (1995). Update on the reli-
ability of diagnosis in older psychiatric outpatients using the Structured Clinical Interview for
DSM-ID-R. Journal of Clinical Geropsychology, 1, 313-321.
Sheikh. J. I. (1991). Anxiety rating scales for the elderly. In C. Salzman & B. D. Lebowitz (Eds.). Anx-
iety in the elderly: Treatment and research (pp. 251-265). New York: Springer.
Sletten. I. W.• & Ullett, G. A. (1972). The present status of automation in a state psychiatric system.
Psychiatric Annals, 2, 77-80.
Spielberger, C. D., Gorsuch, R.. & Lushene, R. (1970). STAI Manual for the State-Trait Anxiety In-
ventory. Palo Alto. CA: Consulting Psychologists Press.
Spielberger. C. D.• Edwards. C. D.• Lushene, R. E.• Montouri, J.• & Platzek. D. (1973). STAIC: Prelim-
inary manual for the State- 'frait Anxiety for children. Palo Alto, CA: Consulting Psychologists
Press.
Spitzer. R. L., Williams. J. B. W., Gibbon, M., & First, M. B. (1988). Structured Clinical Interview for
DSM-III-R-Patient Version (SCID-P 6/1/88). New York: Biometrics Research Department.
New York State Psychiatric Institute.
Stanley, M. A.• Beck, J. G.• & Glassco. J. D. (1996). Treatment of generalized anxiety in older adults:
A preliminary comparison of cognitive-behavioral and supportive approaches. Behavior Ther-
apy. 27, 565-581.
Stanley. M. A.• Beck, J. G., & Zebb. B. J. (1996). Psychometric properties of four anxiety measures
in older adults. Behaviour Research and Therapy. 34, 827-838.
Thompson. L. W., Gallagher. D.• & Breckenridge. J. S. (1987). Comparative effectiveness of psy-
chotherapies for depressed elders. Journal of Consulting and Clinical Psychology, 55,
385-390.
Thompson. J. W.• Burns. B. J., Bartko. J.. Boyd. J. H.• Taube. C. A.. & Bourdon, K. H. (1988). The use
of ambulatory services by persons with and without phobia. Medical Care, 26, 183-198.
Thyer, B. A. (1981). Prolonged in vivo exposure therapy with a 70-year-old woman. Journal of Be-
havior Therapy and Experimental Psychiatry, 12, 69-71.
Thyer, B. A., Parrish, R. T., Curtis, G. C., Nesse, R. M.• & Cameron. O. G. (1985). Ages of onset of
DSM-ID anxiety disorders. Comprehensive Psychiatry, 26, 113-121.
Weiss, K. J. (1994). Management of anxiety and depression syndromes in the elderly. Journal of
Clinical Psychiatry. 55, 5-12.
Weissman, M. Moo Myers, J. Koo TIschler, G. L.• Holzer. C. E.• Leaf. P. J.• Orvaschel, H.• & Brody. J. A.
(1985). Psychiatric disorders (DSM-ID) and cognitive impairment among the elderly in a U.S.
urban community. Acta Psychiatric a Scandinavia, 71, 366-379.
Wengel. S. P.• Burke, W. J.. Ranno. A. E.• & Roccaforte. W. H. (1993). Use ofbenzodiazepines in the
elderly. Psychiatric Annals, 23, 325-331.
Wisocki, P. A. (1988). Worry as a phenomenon relevant to the elderly. Behavior Therapy. 19,
369-379.
Wisocki. P. A.• Handen. B.• & Morse. C. K. (1986). The Worry Scale as a measure of anxiety among
homebound and community active elderly. Behavior Therapist, 9, 91-95.
Zung. W. W. K. (1971). A rating instrument for anxiety disorders. Psychosomatic, 12,371-370.
Zung. W. W. K. (1980). How normal is anxiety? In Current concepts. Kalamazoo. MI: Scope.
CHAPTER 12
Sexual Dysfunction
NATHANIEL MCCONAGHY
AGE AND SEXUAL FUNCTIONING
Age and Decline of Sexuality
The general decline of frequency of sexual activity with age has been consis-
tently documented since it was reported by Kinsey and his colleagues (Kinsey,
Pomeroy, & Martin, 1948; Kinsey, Pomeroy, Martin, & Gebhard, 1953). The Kin-
sey and Hunt (1974) surveys of nonrepresentative samples reported median
weekly frequencies of intercourse declining from 2.5 to 3.3 for people aged 16
to 25 to 0.5 to 1 for those aged 46 to 60 (Seidman & Rieder, 1994). Pfeiffer, Ver-
woerdt, and Davis (1972) investigated 261 White men and 241 White women
aged 46 to 71 chosen randomly from membership lists of the local medical
group, so that they were broadly representative of the middle and upper so-
cioeconomic levels of the community. Ninety-eight percent of the men and 71 %
of the women were married. Cessation of sexual intercourse was reported by
14%,61 %, and 73% of women and 0%,20%, and 24% of men in the age ranges
46 to 50,61 to 65, and 66 to 71; and frequencies of 2 to 3 or more times a week
by 21%,5%, and 0% of women and 33%,7%, and 2% of men in these age
ranges. Of 91 German women of slightly above average education, cessation of
intercourse was reported by 26%,77%,79%, and 100% ofthose in the four age
ranges from 50 to 59 to 80 to 91. The percentages in these age ranges without
sexual partners were 15,44, 75, and 92 (von Sydow, 1995).
Laumann, Gagnon, Michael, and Michaels (1994) surveyed 3,432 subjects,
of whom 3,159 were a 78% representative sample of English-speaking 18-59-
year-olds living in households in the United States. They found number of sub-
jects reporting frequencies of partnered sexual activity in the past year of two or
more times a week declined in men from a maximum of 48% of those aged 25
to 29 to 18% of those aged 55 to 59, and in women from 48% of those aged 25
NATHANIEL MCCONAGHY • Psychiatric Unit, Prince of Wales Hospital, Randwick 2031, New South
Wales, Australia.
239
240 Nathandel~cConaghy
to 29 to 7% of those aged 55 to 59. The percentage reporting no partnered ac-

tivity in the past year increased from 7% of men and 4% of women aged 25 to
29 to 16% of men and 41% of women aged 55 to 59. Laumann and colleagues
reported data for older subjects from the general Social Surveys for 1988 to 1991
and for 1993. These surveys were conducted on about 1,500 respondents yearly,
approximately 75 % of probability samples of individuals aged 18 or over, liv-
ing in households. The percentage with no partnered sexual activity in the past
year increased steadily with age, being reported by 45%, 75%, and 95% of
women aged 60 to 64,70 to 74, and 80 to 84, respectively, and by 16%, 40%,
and 55% of men in these age ranges. Lewontin (1995a), in his trenchant criti-
cism of the validity of self-report of sexual behavior, was scornful of the au-
thors' acceptance "without the academic equivalent of a snicker" of this finding
that 45% of men aged 80 to 84 still have sex with a partner; Sennett (1995) was
interested and cheered by the finding, "even if the aged have confused fantasy
with fact" (p 43). Lewontin (1995b) suggested that "facing the abyss, old peo-
ple need to affirm themselves even more than the young. In a culture that is ob-
sessed with youth, physical vigor, and sexuality, one form of affirmation is
surely sexual boasting" (p. 56). These statements indicated a confident belief
that few if any older people continue sexual activity; this belief was considered
widespread by the men and women aged 50 to over 70 investigated by Brecher
(1984). More than 3,000 agreed and less than 500 disagreed with the statement
that "Society thinks of older people as nonsexual." Findings demonstrating that
the survey evidence to the contrary has some validity were reported by Persson
and Svanborg (1992). Forty-five (56%) of a representative sample of 81 married
men reported having sexual intercourse at the age of 70. Five years later 25 had
ceased, 21 due to factors in themselves. Vasculogenic and stress factors had
been present 5 years earlier in 10 of the 21, compared to one ofthe 20 who were
continuing intercourse. Hence, these factors were predictive of the subjects' re-
ports at 75, supporting their validity.
Duration of the last partnered sexual event, and occurrence in that event
of active and receptive oral sex were also found to decline with age in Laumann
and colleagues' (1994) study. However, anal sex was reported in that event by
42% of men and 1.4% of women aged 55 to 59, both figures higher than the
means for the entire sample. Aging may be associated with an increased accep-
tance of anal stimulation; 16% of the heterosexual subjects in Brecher's (1984)
study of 4,246 socially advantaged men and women reported having had their
anus stimulated during sex since age 50, 86% of the men and 67% of the
women reporting this stating that they liked it.
Investigation of 436 male-partnered women, aged 35 to 59 years, 87% of a
random sample of 600 women registered with two general practices in England,
found age associated not only with reduced frequency of sexual intercourse and
of experiencing orgasm in partnered sexual activity in the preceding 3 months,
but found it was also associated with reduced enjoyment of such activity (Haw-
ton, Gath, & Day, 1994). No enjoyment was reported by 2% of women aged 35 to
39, but 28% of women aged 55 to 59; the activity was considered unpleasant on
all occasions by 1.1 % and 11.3% of women in these age ranges. Brecher (1984)
reported the prevalence of high enjoyment of sex to reduce with age in his older
but health advantaged subjects, from 71 % of women and 90% of men in their
Sexual Dysfunction 241
50s to 61 % of women and 75% of men aged 70 and older. Brecher pointed out
that this decline was less than the decline in the frequency of sexual activity;
prevalence of its weekly incidence reduced from 73% to 50% in women and
90% to 58% in men in the two age ranges. Hawton and colleagues (1994) found
that age of the partner was at least as important as that of the women in deter-
mining frequency of sexual intercourse.
Cohort Effects
These studies reporting decline in sexual activity with age were cross-sec-
tional rather than longitudinal in nature; that is to say, they examined the rela-
tionship in subjects of different ages at one point in time. In cross-sectional
studies, the effects of aging are confounded with the effects of belonging to a
particular age group or cohort. Findings of the studies reported cannot exclude
the possibility that sexual activity of the older subjects had always been less
than that of the younger subjects due, for example, to such factors as different
socialization experiences and religious and moral values. However, although
the subjects investigated by Kinsey and colleagues (1948, 1953), Hunt (1974),
and Pfeiffer and colleagues. (1972) were less representative than those of Lau-
mann and colleagues (1994), the fact that 40 and 20 years previous to recent
studies they reported comparable declines in sexual activity with age suggests
it is unlikely that such declines could be accounted for solely by a cohort effect.
Pfeiffer and colleagues (1972) attempted to examine the effect of age in isolation
by asking subjects if they were aware of a change in their sexual interest and ac-
tivity. The number who reported awareness of a decline in sexual interest and
activity increased with age, the largest increase being found between subjects in
the age groups 46 to 50 and 51 to 55. Decline was reported by 58% of women
aged 46 to 50,78% of women aged 51 to 55, and 96% of women aged 66 to 71;
and by 49% of men aged 46 to 50, 71 % of men aged 51 to 55, and 88% of men
aged 66 to 71. In what could seem a conflicting report, Adams and Turner
(1985) stated that they found that women more than men reported increases
from young adulthood to old age on one or more sexual measures. They should
have said the minority of their subjects who reported increases consisted more
of women than of men. They asked 62 women and 40 men aged 60 to 85 years
to rate the sexual measures currently and when they were age 20 to 30. The
highest percentage reporting an increase were 17% of women in regard to fre-
quency of orgasm; 5 % of men reported an increase. However, frequency was re-
ported to stay low or decrease by 70% of women and 62% of men. Frequency of
orgasm in women tends to increase from early adulthood until middle age (Mc-
Conaghy, 1993), so a more meaningful comparison for the current rating would
have been with their rating when they were aged 35 to 45. Brecher (1984) found
more women than men aged 50 and over reported increase in interest in sex
compared to when they were aged approximately 40. However, the majority of
both sexes reported interest in sex was about the same or had decreased.
Longitudinal studies, that is, studies following up the same subjects over
time, are methodologically the most appropriate to investigate the influence of
age independent of cohort effects. Hallstrom and Samuelsson (1990) investigated
242 Nathaniel McConaghy
initially and 6 years later 497 Swedish women living with their spouse or other
partner who were part of an 89% representative sample of a town population. At
follow-up in only a minority of each age group, 7%, 26%, 31%, and 37% of
those finally aged 44, 52, 56, and 60 respectively, had the strength of sexual de-
sire declined over the 6 years. George and Weiler (1981) investigated frequency
of sexual intercourse in 108 married women and 170 married men, studied ear-
lier by Pfeiffer and colleagues (1972). No decline over 6 years was present in
62%,56%, and 33% of the women finally aged 52 to 61, 62 to 71, and 72 to 77,
respectively. No sexual activity over the previous 6 years was reported by 5% of
women finally aged 52 to 61 and 62 to 71, and by 33% of those finally aged 72 to
77; a further 5%,22%, and 33% respectively, of those in these three age ranges
ceased intercourse during the same period. In the men followed up, as in the
women, frequency of sexual intercourse remained stable over the 6 years in the
majority of those finally aged 52 to 71; it was also stable in 42% of men finally
aged 72 to 77. No activity was reported from the commencement of the period of
the study by 0%,9%, and 12% of men finally aged 52 to 61, 62 to 71, and 72 to
77 respectively, and a further 5%, 7%, and 18% of men in these age groups
ceased activity. Cessation of sexual activity in the 66% of women and 30% of
men finally aged 72 to 77 in this study of economically advantaged married sub-
jects could be in part a cohort effect, as the follow-up was only over 6 years. As
Marsiglio and Donnelly (1991) pointed out in their report of what they believed
was the first nationally representative data on the sexual frequency patterns of
elderly persons, this effect can only be assessed when future representative data
become available.
Importance of an Established Partner for Sexual Activity

in Older Women
Pfeiffer and colleagues (1972) reported 97 women and 35 men who gave
reasons for why they ceased sexual relations: 90% of the women attributed re-
sponsibility for stopping intercourse to absence of a spouse due to death, sepa-
ration, or divorce, or to his illness or inability to perform sexually. Seventy-one
percent of the 35 men who reported cessation of intercourse accepted that they
were responsible due to illness, loss of interest, or inability to perform sexually.
Regression analysis showed a number of factors to be associated with reduced
current sexual activity in men (Pfeiffer & Davis, 1972). These included less past
sexual activity, age, poor health status, lower social class, taking of antihyper-
tensive medication, and reduced life satisfaction. Markedly fewer factors were
associated with reduced sexual activity in women, but accounted for a greater
percentage of the total variance than did the larger number of factors in men.
Those for women were principally no intact marriage and age. Less education,
being unemployed, and postmenopausal status made small contributions. As
could be expected, in their 6-year follow-up of the subjects studied by Pfeiffer
and colleagues (1972), George and Weiler (1981) reported that both the (mar-
ried) men and women overwhelmingly attributed cessation of sexual relations
to attitudes or physical condition of the male partner. They considered this tes-
tified to the importance of the man's role as initiator of sexual behavior among
current cohorts of middle-aged and older adults. Findings supporting this con-
clusion were reported by Persson and Svanborg (1992). Of 25 men who ceased
having sexual intercourse with their wives between the ages of 70 and 75, 21 at-
tributed cessation to factors in themselves: lack of ability in 8, own illness in 4,
and loss of interest in 9. Bretschneider and McCoy (1988) investigated by
anonymous questionnaire 202 upper-middle-class White men and women, aged
80 to 102, living in retirement facilities for the healthy elderly, none of whom
were taking regular medication. One of the six most frequently experienced sex-
ual problems reported by 30% of women was their partner's inability to achieve
or maintain erection. Lack of sexual interest was reported by 25% of the women
but was not one of the six most common problems of men. Despite the women,
in Pfeiffer and colleagues' (1972) study considering absence of an effective part-
ner responsible for cessation of intercourse, they reported a much greater re-
duction of sexual interest in relation to their age than did the men. A quarter of
women in their 50s and 50% in their 60s reported no sexual interest; corre-
sponding figures for men in these two age ranges were less than 5% and 10%.
It would seem that in the absence of an effective partner many women lose sex-
ual interest and cease all sexual activity. The importance of an intact marriage
in maintaining women's sexual activity, that is, partnered sex or masturbation,
was demonstrated in Brecher's (1984) questionnaire investigation of 4,246 men
and women 50 to over 70 years of age who were above average in education,
health and income. The percentages of married women who were sexually ac-
tive were 95, 89 and 81 for the age ranges 50 to 59, 60 to 69 and 70 and over;
percentages of sexually active unmarried women ofthe same ages were 88,63,
and 50. Equivalent percentages for married and unmarried men were 98, 93,
and 81, and 95,85, and 75.
Although the relationship of marriage and sexual activity does not appear
to have been investigated in representative population samples of older people,
fewer unmarried as compared with married women must have reported having
sexual activity to account for disparities in the percentages of subjects reporting
no partnered sexual activity in the representative studies of married subjects re-
ported by Marsiglio and Donnelly (1991) and of the total population reported by
Laumann and colleagues (1994). In the former study, of the 66% who answered
the question, 35%, 45%, 55%, and 76% respectively ofthose aged 61 to 65, 66
to 70, 71 to 75, and 76 or older reported they had not had sex with their spouse
in the past month. The percentage of women stating they had not had sex was
only slightly less than that of the men, consistent with the authors' statement
that any time a husband has sex a wife also will be having sex. Laumann and
colleagues reported for comparable age ranges that 45%,60%,75%, and 80% of
women and 16%, 25%,40%, and 45% of men reported no partnered sexual ac-
tivity in the past year. Laumann and colleagues also reported that by the age of
60, more than 20% of men and women report frequencies of a few times a year.
Hence, a significant number of these subjects would be included in Marsiglio
and Donnelly's (1991) but not in Laumann and colleagues' (1994) study as not
having sex. Despite Laumann and colleagues' study including this 20% of
women in the percentage having partnered sex, it still found a much higher per-
centage of married and unmarried women combined not having partnered sex
than did Marsiglio and Donnelly's (1991) study of married women only.
Inclusion in Marsiglia and Donnelly's (1991) study of many of the men hav-
ing partnered sex a few times a year in the percentage of men not having it
would account for their finding a higher percentage of married men not having
partnered sex than the married and single men in Laumann and colleagues'
(1994) study. Not allowing for their different treatment of men having partnered
sex a few times a year, the findings of the two studies would indicate that a
higher percentage of unmarried than married older men had partnered sex. Al-
lowing for the different treatment, the findings still indicate that marriage is not
a major factor determining maintenance of partnered sex in older men. Evi-
dence that marriage is a major determinant of partnered sex in older women but
not men was also found in a Swedish study of 70-year-old subjects cited by
Bretschneider and McCoy (1988); 46% ofthe men and 14% of the women were
sexually active; only 2% of the unmarried women but 36% of married women
and 52% of married men reported having sexual intercourse. Commenting on
the dearth of older unmarried men compared to women, Brecher (1984) pointed
out that official figures in the United States at the time were that for people over
50 years of age there were 2.7 unmarried women for every unmarried man, and
for those 65 or older, the figures were 3.3 for one. He added that these figures se-
riously underestimated the problem. More unmarried men than women were
already involved (in his study 57% of men compared to 33% of women had a
regular sexual partner); and more considered themselves homosexual (10%
compared to 1 % of unmarried women in his study). Applying these percent-
ages to the official figures, Brecher concluded that there were five unattached
heterosexual women for every unattached heterosexual man in his subjects over
50 years of age. The unmarried women's regular male partners were mainly
married or much older or both; those of unmarried men were mainly much
younger women. Von Sydow (1995) investigated use of what she termed un-
conventional relationships by 91 German women aged 50 to 91 to compensate
for the shortage of single male partners. Nine were in such relationships, one
with a woman, four with younger men, and four with men living with their
wives. She found the women in the relationships had been in similar relation-
ships when younger so there was little evidence that they had adopted these
patterns as solutions to the dilemma of being elderly and without an appropri-
ate male partner.
Additional differences between the sexes reflecting men's greater sexual
opportunities were Brecher's (1984) finding that of unmarried subjects 34% of
men and 13% of women had had sex with one or more casual partners in the
previous year, and older men were presumed more likely than women to have
sex with prostitutes. Of the 2,402 men he investigated 34% reported experi-
ences with female prostitutes prior to age 50, and 7% since, 2.5% in the last
year. Brecher suggested that low use of female prostitutes by men in part re-
sulted from their ability to find voluntary women partners. Older homosexual
men may be less able to find suitable voluntary partners; 20% of the 86 men in
his study who reported homosexual activity since the age of 50 had used male
prostitutes. Women respondents were not asked about activities with prosti-
tutes. Johnson, Wadsworth, Wellings, Field, and Bradshaw (1994) in their 60%
representative sample of British men and women aged 16 to 59 found that the
odds ratio for payment of women by men for sex increased rapidly with age and
was significantly more likely for men who were cohabitees, widowed, sepa-
rated, or divorced than for married men. Pfeiffer and Davis (1972) considered
the remedy for the lack of sexual partners for older women to lie in efforts to
prolong the vigor and life span of men.
Sexual Activities Apart from Intercourse
Although frequency of sexual activities apart from intercourse have been

investigated in older persons it is not clear to what extent they are employed as
substitutes when intercourse ceases due to inability or absence of a partner.
Studies frequently do not adequately define terms leaving it uncertain, for ex-
ample, whether masturbation is carried out alone, with a partner watching, or
as mutual masturbation, whether sexual activity includes unpartnered mastur-
bation, and whether partnered sexual activity requires penetrative intercourse.
Reiss (1995) pointed out, in regard to the survey by Laumann and colleagues
(1994), that the definition of sexual activity used specified that it did not
require that intercourse or orgasm occur. However, subjects were given the def-
inition after completing a questionnaire containing questions about sexual ac-
tivity, but before a face-to-face interview. Yet very few differences were found in
the number of partners reported in the two procedures, causing Reiss to con-
clude that the subjects were not following the definition in the interview and
were ignoring partners with whom they had only genital petting. The issue is of
importance in regard to the sexuality of the elderly, as many therapists encour-
age them to adopt other sexual practices when they cannot maintain penetra-
tive intercourse.
Of the 202 advantaged subjects investigated by Bretschneider and McCoy
(1988),53% percent of the men and 25% of the women said they had at least
one regular sex partner, including the 29% of men and 14% of women who
were married. Of those with partners, 82% of the men and 64% of the women
were at least mildly happy with them as lovers. Seventy percent of all the men
and 50% of all the women fantasized or daydreamed often or very often about
being close, affectionate, and intimate with the opposite sex. Forty-seven per-
cent of the women and 22% of the men considered sex of no importance.
Touching and caressing without sexual intercourse was the most common ac-
tivity for men (83%) and women (64%), then masturbation for men (72%) and
women (40%), followed by sexual intercourse for men (62%) and women
(30%). Masturbation, as investigated in this study, was presumably not a part-
nered activity. Genital petting was assessed separately, and many of the subjects
did not answer concerning masturbation, the percentage reported being based
on the answers of those who did. Frequency of the activities investigated cor-
related positively, suggesting that none was a substitute for others. Current fre-
quency and enjoyment of the activities was less than in the past, reduction
being most marked in relation to intercourse and least marked in relation to
masturbation.
Brecher (1984) reported anecdotal evidence of men and women aged 50
and over using masturbation, at times with vibrators, when penetrative inter-
course became impossible, but did no report of the percentage who did so as
part of sexual activity with a partner. More single than married subjects in his
study masturbated presumably alone: 63% versus 52% of men and 54% versus
36% of women. The most frequent reason given was absence of an acceptable
partner. Incidence declined with age from 66% of men and 47% of women in
their 50s to 43% of men and 33% of women 70 and older, indicating that most
women and men do not use masturbation to compensate for cessation of coitus.
The percentage of women and men having sex with their spouses declined from
88% to 65% and 87% to 59%, respectively, for those in the same age ranges.
The mean frequency in subjects who continued masturbation declined from 1.2
to 0.7 per week in men but remained the same in women in these age ranges;
Brecher commented that it was the only one of the measures of sexual activity
reported that did not show a decade-by-decade decline. He did not report the
relationship of the use of masturbation to cessation of coitus. However, of his 38
women subjects aged 80 and over, sexual intercourse was reported by 3, other
partnered sexual activity by a further 2, and unpartnered sexual activity, pre-
sumably masturbation, by 10. Of his 76 male subjects, sexual intercourse was
reported by 25, other partnered sexual activity by a further 4, and nonpartnered
sexual activity by 17; 29 said they masturbated, presumably including 12 of
those having partnered sex Brecher reported that an unstated percentage of men
with erectile difficulty used "stuffing," inserting the inadequately erect penis
into the vagina. He considered his subjects' use of sexual fantasy and sexually
explicit material as countermeasures to the decline in sexuality with aging. Use
of sexual fantasy was reported by 89% and 61 % of his male and 74% and 52%
of his female subjects during masturbation and partnered sex, respectively. The
content was stated to include homosexual and "ego-alien" material. Use of sex-
ually explicit reading material and hard-core pornographic films or photos was
reported respectively by 37% and 18% of the women and 56% and 42% of the
men. These prevalence figures are in the same range as those found in younger
subjects (McConaghy, 1993), so that use of these stimuli as a continuation of
earlier practices would need to be excluded before it can be accepted that they
are adopted as compensatory by older people.
A Danish questionnaire study, mainly of men aged 51 to 95, found that
only 3% of those in their 90s reported having coitus, although 28% had part-
ners and 35% reported that they were still interested in sex (Hegeler &
Mortensen, 1978). Prevalence of cessation of coitus with age increased more
rapidly after the age of 70. Prevalence of cessation of masturbation increased
more slowly; it was reported by 60% of men aged 51 to 55 years and 23% of
those aged 90 to 95 "confessed" to its use. A further 31 % in that age group did
not answer concerning masturbation; the authors interpreted comments made
as indicating that considerable guilt still existed about masturbation, suggesting
the masturbation assessed was not a partnered activity. In their investigation of
healthy married men, Weizman and Hart (1987) found that 51 % of those aged
66 to 71, but only 27% of those aged 60 to 65 reported masturbation; 26% of the
older and 9% of the younger men masturbated more than four times a month.
Intercourse was reported by 64% of both groups, 64% of the younger and 47%
of the older men reporting frequencies of more than four times a month. The re-
lationship of presence and frequency of masturbation and intercourse was not
reported, but the authors assumed that they were negatively related. As stated
previously, Bretschneider and McCoy (1988) found them positively related in

their study of older persons, as did Martin (1981) in 188 mostly White well-
educated married men aged 60 to 79 years who had volunteered for a Baltimore
study of aging.
Masturbation was reported by 37%,33%,29%, and 8%, respectively, of91
German women of slightly above average education in the four age ranges from
50 to 59 through 80 to 91; the reduction in prevalence somewhat paralleled that
of intercourse, which was 74%, 23%, 21 % and 0% of subjects in the same age
ranges (von Sydow, 1995). The author did not comment as to what extent mas-
turbation was a continuation of its earlier use rather than compensatory for the
decline in intercourse. Leiblum, Bachmann, Kemmann, Colburn, and Swartz-
man (1983) reported of the 52 postmenopausal women aged 50 to 65, that those
having intercourse three or more times monthly masturbated more frequently
than those having intercourse less than ten times yearly. They also had higher
frequencies of giving and receiving manual and oral genital stimulation.
In Martin's (1981) study, coitus and masturbation in the past year was re-
ported by 93% and 32%, respectively, ofthe sexually most active men, and by
40% and 17%, respectively, of the sexually least active. However, on the basis
of their assumption of a negative relationship between frequency of coitus and
masturbation, Weizman and Hart (1987) concluded that with advanced age in-
terest in sexuality continues but the form of sexual expression changes from ac-
tive sexual intercourse to masturbation even with the availability of the same
partner. They attributed at least part of the change to decline in social status and
self-confidence in masculinity due to retirement. All the younger men were
working full-time and all the older men were retired. A possible influence of in-
creased leisure time associated with retirement on the use of masturbation was
not considered and indeed does not seem to have been explored in relation to
the sexual activity of the elderly. Of the 60-85-year-old subjects investigated by
Adams and Turner (1985), masturbation was reported by 46% and 56%, re-
spectively, ofthe unmarried women and men and 13% and 16% ofthe married
women and men. Adams and Turner found that in men, but not women, mas-
turbation represented a continuation from their earlier life; the authors con-
cluded that the older women's sexuality was more plastic. Their figure of 16%
of elderly married men reporting masturbation was considerably below that of
the studies reviewed previously, which were all of subjects of above-average
health and socioeconomic level. Their subjects may have been more represen-
tative of the total population in these respects. Laumann and colleagues (1994)
found that percentages of subjects in their representative sample who reported
privately masturbating at least once a week in the previous year declined from
about 30 in the younger men to about 12 in those aged 50 to 59; and from about
10 in the younger women to 2.4 in those aged 50 to 59. The percentage report-
ing not masturbating at all over the past year fell from 41 % and 64 % of the
youngest men and women to 28% of men aged 30 to 34 and 50% of women
aged 40 to 44, to rise again to 50% of men and more than 70% of women aged
50 to 59. Although the relationship with socioeconomic status as a whole was
not reported there was a strong positive relationship of level of education and
use and frequency of masturbation. Like Bretschneider and McCoy's (1988)
study of upper- middle-class subjects aged 80 to 102, that of Laumann and col-
leagues (1994) found little evidence that masturbation was used as a substitute
for intercourse. This was also the case in the 60-85-year-old subjects who re-
ported change in their preferred sexual activity from the age of 20-30 (B. F.
Turner & Adams, 1988). Of the 26 who ceased to prefer heterosexual inter-
course, only 4 preferred masturbation; 15 selected petting, 3, dreaming, 2, day-
dreaming, 1, homosexual activity, and 1, other activity. An interesting finding
in Brecher's (1984) study of advantaged subjects 50 years and older was that
61 % of women but only 18% of men reported higher frequencies of experienc-
ing orgasm with masturbation than with partnered sex, 16% of women and
26% of men reported the reverse, and the remaining 24% of women and 56% of
men reported the same frequencies for the two activities. If replicated, the find-
ing indicates that at least older women experience orgasm more readily with
masturbation than with partnered sex. It might seem that this would encourage
older women to use masturbation if partnered sex is unavailable, but this is
contrary to the evidence discussed. Their failure to do so is consistent with the
conclusion that women's sexuality is much more dependent than is men's on
the existence of an emotional relationship with a partner (McConaghy, 1993).
Health and Socioeconomic Status and Partnered Sex
Bretschneider and McCoy (1988) concluded that people experienced a

small steady increase in loss of interest in sex and cessation of intercourse
from their late 40s, an increase which continued in men into their 90s, but
ceased in women after they reached the age of 80. They reached this conclu-
sion from comparison oftheir subjects aged 80 to 102 with the 66-71-year-old
subjects of Pfeiffer and colleagues (1972). Percentages of older women without
interest in sex or who were not having intercourse (about 45% and 70%, re-
spectively) were the same or less than those of the younger women, whereas
equivalent percentages of older men (about 20% and 37% respectively) were
higher than those of the younger men. Bretschneider and McCoy (1988) further
concluded that the major decline in sexual activity occurred in women in their
late 50s and early 60s and could be related to the menopause and the associ-
ated fall in hormone levels. Their conclusions, based on a possibly invalid
comparison of these two groups of nonrepresentative subjects who were above
average in health and socioeconomic advantage, were not supported by
Brecher (1984). He found prevalence of any sexual activity in 38 women and
76 men aged 80 and over was 39% and 61%, respectively lower than the
equivalent prevalences of 65% and 79% in his subjects aged 70 and over,
which in turn were lower than the prevalences of 81 % and 91 % in those in
their 60s, and 93% and 98% of those in their 50s. The sexual activity of the
80-102-year-old subjects investigated by Bretschneider and McCoy (1988) was
higher than that of comparably aged subjects studied by Brecher (1984). In the
former study 62% of the men and 30% of the women reported having sexual
intercourse, compared with 33% of men and 8% of women aged 80 or more in-
vestigated by Brecher, and 72% of men and 40% of the women reported mas-
turbation, compared with 43% of men and 33% of women aged 70 and older
in Brecher's study. Although the subjects in both groups were advantaged in

health and socioeconomic status compared with the normal population. the
degree of advantage may have been greater in those studied by Bretschneider
and McCoy (1988). Certainly Bretschneider and McCoy's findings in regard to
sexual activity of older persons cannot be generalized. Percentages of their
healthy subjects who maintained partnered sexual activity after the age of 80
was markedly higher than those of the representative sample reported by Lau-
mann and colleagues (1994), which were 45% of men and 5% of women. Of
250 residents of nursing homes in Texas whose mean age was greater than 80,
91 % were sexually inactive; that is, they had not masturbated or had inter-
course in the previous month (White, 1982). All were able to be interviewed in
that they could give valid responses to a mental status questionnaire and to the
interview questions; about two thirds were women. Of the sexually inactive,
17% said they would be interested in being sexually active but lacked oppor-
tunity, having no partner or lacking privacy.
In contrast to the findings of higher frequencies of sexual activity in groups
of healthy as compared to less healthy older persons, Brecher (1984) reported
that when the effect of age was statistically controlled for, the decade-by-decade
increase in impaired health of his subjects had only a weak relationship with
the parallel decline observed in most measures of sexual activity. His finding
could have resulted from the limited range of degree of health of the subjects,
which was better than average. This explanation would not account for Mar-
siglio and Donnelly'S (1991) finding, in their study of a representative popula-
tion sample of subjects more than 60 years of age, that regression analysis
demonstrated a relationship with the spouse's but not the subject's health and
the likelihood of their engaging in sex; the health of neither was related to fre-
quency. Subjects assessed their health in relation to that of others of their age.
This may be a poor measure of subjects' actual level of health. Johnson and col-
leagues (1994), using a similar question, found only a moderate relationship be-
tween health and age in their subjects aged 16 to 59; of those with health
problems more than one in five considered their health good. They found a
weak relationship between reduced frequency of heterosexual intercourse and
poor health. Laumann and colleagues (1994) asked their subjects whether they
would say their health was excellent, good, fair, or poor. They found a strong re-
lationship between their subjects' health on this measure and their interest in
having sex. Also 43% of 60-80-year-old men and women who reported very
good health stated that sexuality was important to them, significantly more than
the 15% stating this who reported bad physical health (Bergstrom-Walan &
Nielsen, 1990).
It would seem that although older middle-aged women report less sexual
interest and activity than younger ones, the difference in the majority of the
healthy and socially advantaged is not great. They can expect their sexual in-
terest and frequency of coitus to remain relatively unchanged into their 60s pro-
vided they have an active sexual partner, although some will experience a
reduced ability to enjoy sexual activity or reach orgasm The decline in fre-
quency of coitus in these women during and following their 60s appears to be
largely determined by reduced ability or interest or loss of their male partners.
Biological Factors and Sexual Activity
Biological factors may playa larger role in the decline in sexuality with age
in men as compared with women. Martin (1981) investigated possible reasons
for the different levels of sexual interest and activity in 188 well-educated mar-
ried men aged 60 to 79. Twenty-six percent had not experienced marital coitus
for at least a year. Combining frequency of coitus, masturbation, nocturnal emis-
sions, and homosexual activity, Martin found this measure of sexual expression
was independent of marital adjustment, sexual attractiveness of wives, and sex-
ual attitudes, but strongly related to the subjects' reported frequency of sexual
behaviors from the age of 20. The relationship of current and earlier levels of
sexual activity was also found in men in their 40s or older in studies Martin re-
viewed, including that of Pfeiffer and Davis (1972). When the men in Martin's
(1981) study were asked if they would seek treatment to obtain greater sexual
vigor if such treatment were possible, 29% of the least and 31 % ofthe most sex-
ually active men said they would do so. Martin concluded that the finding that
the large majority of his subjects were well satisfied with the current sexual sit-
uation was compatible with the observation that their decline in sexual func-
tioning with age resulted from a corresponding decline in motivation, and the
finding that most respondents had maintained comparatively high or low rates
of activity over a large part of their lives suggested they did so because of char-
acteristic differences in level of motivation. These differences could result in
part from biological determinants. White (1982) reported a relationship in 250
nursing home residents, of whom about two thirds were female, between their
reported frequency of feeling sexually aroused and of sexual intercourse, but
not of masturbation, with their self-assessment of level of sexual activity
throughout life. However, Pfeiffer and Davis (1972) did not find a relationship
between frequency of sexual activity in early and later life in women. Also,
Martin pointed out that Christenson and Gagnon (1965) found that women in
their 50s and 60s who were married to older men were much less active sexu-
ally than women married to younger men.
Tsitouras, Martin, and Harman (1982) investigated 183 men aged 60 to 79
years who were part of the Baltimore longitudinal study on aging and were of
above-average health. They found the usual reduction in sexual activity with
increased age but no reduction in total testosterone levels. Tsitouras and col-
leagues cited other studies that also found no reduction in testosterone levels of
healthy older men and suggested that when it was found it was due to such ac-
companying factors as obesity, alcoholism, chronic disease, and stress (all of
which were known to affect the level of the hormone). Although Tsitouras and
colleagues found a relationship between their subjects' testosterone levels and
amount of coital and masturbatory activity, it was much less than the relation-
ship of the level of these activities with age. Testosterone levels did not show a
significant relationship with their subjects' erectile ability, consistent with the
evidence that reduction oflevels oftotal testosterone to 30% of subjects' previ-
ous levels reduces sexual interest but not erectile ability (McConaghy, 1993).
In a contrasting finding to that of Tsitouras and colleagues (1982), Korenman
and colleagues (1990) found that healthy and sexually potent men (mean age
65) showed significantly lower levels of total and bioavailable testosterone
compared to 57 healthy potent men aged 20 to 44. Using limits of 10.5 and 2.3
nmol/L for the total and bioavailable testosterone assessments, respectively (2.5
SDbelow the means of the younger men), 24% and 48% of the older men were
hormonally hypogonadal. Korenman and colleagues did not report their sub-
jects' sexual interest and activity levels. Chambers and Phoenix (1982) pointed
out that the decline in the sexual performance of aging males is a general phe-
nomenon found in several different mammalian species, including rodents,
farm animals, and nonhuman primates, as well as in human beings. They noted
that decline in aged rhesus monkeys could not be attributed to reduction in
testosterone levels, as there is no change in these levels with age.
SPECIFIC SEXUAL DYSFUNCTIONS
DSM-IV Classification
As classified in the Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV; American Psychiatric Association, 1994) the sexual dysfunctions in-
clude the Sexual Desire Disorders of Hypoactive Sexual Desire and Sexual
Aversion; the Sexual Arousal Disorders of Female Sexual Arousal Disorder, in-
ability to attain or maintain an adequate genital lubrication-swelling response
of sexual excitement until completion of sexual activity, and Male Erectile Dis-
order; the Orgasm Disorders of Female and Male Orgasmic Disorders and Pre-
mature Ejaculation; and the Sexual Pain Disorders of Dyspareunia, genital pain
in either males or females before, during, or after sexual intercourse, and Vagin-
ismus (involuntary spasm of the musculature of the outer third of the vagina
that interferes with sexual intercourse). To receive the diagnosis of sexual dis-
order in these four categories, DSM-W criterion A requires that the condition be
recurrent or persistent, and criterion B that the disturbance causes marked dis-
tress or interpersonal difficulty. Criterion B presumably allows absence of or-
gasmic capacity to not be considered a dysfunction in at least some of the
women in many surveys who reported that they enjoyed intercourse very much
although they did not reach orgasm (McConaghy, 1993). The various criteria
comprising A instruct the clinician to take into account such factors as the per-
son's age, adequacy in focus, intensity, and duration of the sexual experience,
and the novelty of the sexual partner or situation. However, the criterion gives
no operationally defined guidelines as to how to take these factors into account,
making it unlikely that the reliability of the diagnoses made by different clini-
cians using these criteria will be high.
Prevalence
Information concerning prevalence of sexual dysfunctions in representative

groups of older subjects is limited; few studies of the prevalence of sexual dis-
orders in the adult population have been undertaken; and those that have been
tended to use different diagnostic criteria and exclude older subjects. Laumann
and colleagues (1994) asked their 18-59-year-old subjects whether in the previous
12 months there had ever been a period of several months or more when they ex-
perienced particular sexual dysfunctions. There was a marked difference between
prevalences oflack of interest in sex and inability to achieve orgasm in (1) repre-
sentative American women subjects surveyed, (2) the representative sample of
Swedish women living with their husbands or other partners in whom Hallstrom
(1979) investigated prevalence oftotal inability to achieve orgasm, and (3) in Hall-
strom and Samuelsson's (1990) investigation of prevalence of absence of sexual
desire. Prevalence of both dysfunctions in the Swedish women showed a marked
increase with age in those older than 46. In the American women prevalence of
orgasmic dysfunction showed no clear relationship with age, and that of having
trouble lubricating reduced until age 45, after which it showed a moderate in-
crease, which remained at relatively the same level over the age range 45 to 59.
Also, prevalences in the Swedish women aged 38 and those aged 46 of absence of
desire (3%-4%) and anorgasmia (10%-12%) were much lower than those in
women aged 35 to 44 in Laumann and colleagues' (1994) study (36% and 23% re-
spectively). These findings seem related to prevalences in older women showing
a marked increase in the Swedish study but remaining relatively unchanged in
the American study. The disparities seem too great to have resulted from the fact
that all the Swedish women were partnered; 29% of the married women in Lau-
mann and colleagues' study reported lack of interest and 22% reported inability
to achieve orgasm. The disparities also seem unexplained by differences in the
eliciting questions. Laumann and colleagues (1994) asked about a period of sev-
eral months or more in the past 12 months, and Hallstrom and Samuels son (1990)
about present experience. The Swedish women were representative of the popu-
lation of an industrial town, again a difference that seems unlikely to explain the
disparities. They could reflect cultural differences in the assessment of sexual ac-
tivities. Osborn, Hawton, and Gath (1988) investigated percentage of women aged
35 to 59 years registered with two general practices in England, who reported im-
paired sexual interest and anorgasmia in partnered sexual activity in the past 3
months. They reported a prevalence more similar to that found by Hallstrom and
Samuelsson (1990), though onset of its increase was more gradual and com-
menced earlier from the age of 40. The dearth of studies of the prevalence of dys-
functions in representative samples of older people clearly requires correction to
clarify the causes of disparities in those studies available.
Laumann and colleagues (1994) found that lack of interest in having sex, not
finding sex pleasurable, being unable to come to a climax, and experiencing
physical pain during intercourse were reported by a much higher percentage of
women than men in all age ranges. Coming to a climax too quickly and feeling
anxious about their ability to perform sexually was reported by more men than
women. Having trouble achieving or maintaining an erection was reported by
fewer younger, but the same percentage of older men as the percentage of women
reporting having trouble lubricating. Erectile difficulty was the dysfunction in
men that showed the clearest relationships to age. It was reported by as many as
10% of men aged 18 to 49 but 21 % of men aged 50 to 59. Its prevalence in most
studies of men selected for health or who were socioeconomically advantaged
was little different. Rates in the largely healthy men investigated by Kinsey,
Pomeroy, and Martin (1948) were 1 % at 30,2% at 40, 7% at 50,18% at 60,27%
at 70, 55% at 75, and 76% at 80 years of age. Of men above average in health and
in a stable relationship, 23% of those aged 55 to 64 and 32% ofthose aged 65 to

74 reported difficulty in achieving vaginal insertion in 50% or more of coital at-
tempts in the preceding 6 months (Schiavi. Schreiner-Engel, Mandeli, Schanzer,
& Cohen, 1990); 36% of healthy happily married men aged 60 to 71 reported ab-
sence of erection during sexual activity (Weizman & Hart, 1987). Inability to at-
tain an erection was present in 28% and inability to maintain an erection in 33%
of upper-middle-class men aged 80 to 102 (Bretschneider & McCoy, 1988). The
percentage with one or the other was not given. Lack of spontaneous erections
during day or night was reported by 65% of men in Weizman and Hart's (1987)
study. It was not stated whether such lack included difficulty in achieving erec-
tion without manual stimulation of the penis during sexual activity with a part-
ner, a difficulty increasingly experienced by men after the age of about 50
(Brecher, 1984). Its prevalence does not appear to have been specifically docu-
mented. Other erectile changes in men aged 50 and over were longer refractory
period, taking longer to get erections, erections less rigid, and more frequent loss
of erection during sex, reported respectively by 65%,50%,44%, and 32% of
Brecher's subjects. Brecher also pointed out that ejaculation may be less forceful
with fewer contractions and reduction in amount of ejaculate. Men concerned
about such changes need to be informed that they are normal aspects of aging.
Despite impairment of the genital lubrication-swelling response of women
being regarded as the sexual arousal disorder equivalent to erectile dysfunction
in men, its prevalence has been less frequently investigated so that there is lit-
tle evidence to determine whether it is lower in subjects who are more healthy
than those representative of the total population. However, it is established that
its prevalence increases with age. Having trouble lubricating was reported by
21 % to 24% of the representative sample of women in the age ranges 45 to 59,
higher than the percentage of younger women reporting the problem (Laumann
et ai., 1994). Osborn and colleagues (1988) reported that the prevalence of vagi-
nal dryness in English women attending two general practices increased
steadily from 8% in women aged 35 to 39 to 26% in women aged 50 to 54, and
then reduced to 22% in women aged 55 to 59. It was one of the most common
six problems in advantaged women aged 80 to 102, being reported by 30%
(Bretschneider & McCoy, 1988). The percentage of advantaged women studied
by Brecher (1984) who reported "about the right amount" of vaginal lubrication
during sexual arousal decreased from 48% of those in their 50s to 23% of those
aged 70 and over.
Prevalence of inability to orgasm showed no relation with age in men and
a small decline in women in a representative sample of subjects in the United
States aged 18 to 59 (Laumann et ai., 1994). It was present in just over 10%, just
under 10%,15%, and 25% of women aged 38, 46,50, and 54, of the represen-
tative sample of partnered Swedish women (Hallstrom, 1979). As discussed ear-
lier, the much higher prevalence of inability to achieve orgasm in younger
women in the former compared to those in the latter study could account for
opposite trends that the two studies reported in the relationship of the preva-
lence of anorgasmia to age in women. The decline in orgasmic ability with age
found in the Swedish study was also found in studies of nonrepresentative
samples whether or not selected for health and socioeconomic advantage. In
English women attending general practitioners anorgasmia in partnered sexual
activity in the past 3 months was present in 5%, 8%, 14%, 21%, and 35%, re-
spectively, in the five age ranges from 35 to 39 through 53 to 59 (Hawton et al.,
1994). The percentage always reaching orgasm declined steadily from 24% to
12% over the same age range. Degree of ability to regularly reach orgasm re-
ported by male veterans was over 80%,72%,61%,48%,40%, and 21%, in
those aged 30 to 49, 50 to 59, 60 to 69, 70 to 79, 80 to 89, and 90 to 99, respec-
tively (Mulligan & Moss, 1991). This dysfunction was one of the six most fre-
quent problems of the advantaged subjects aged 80 to 102 with regular partners
studied by Bretschneider and McCoy (1988), being experienced by 30% of
women and 28% of men. These percentages were higher compared with the
22% of women and 9% of men aged 55 to 59 years who had the dysfunction in
Laumann colleagues (1994) study, but comparable for women with the 35% of
partnered women aged 55 to 59 years reporting anorgasmia who saw two gen-
eral practitioners (Hawton et al., 1994). The advantaged subjects investigated by
Brecher (1984) reported a lower prevalence of anorgasmia than the subjects of
the same age more representative of the total population investigated in the
studies mentioned. In Brecher's study only 1 % of men and 19% of women aged
50 to 59 reported seldom or never reaching orgasm in partnered sex; the per-
centages rose to 10 and 28, respectively, in those aged 70 and over. Seldom or
never experiencing orgasm with masturbation was reported by fewer women
but more men: 7% and 14% women and 4% and 13%, respectively, of men in
these two age ranges. It appears that orgasmic ability is maintained at a higher
level in the more healthy elderly compared to subjects of the same age more
representative of the general population.
Prevalence of lack of interest in sex showed a slightly stronger increase
with age in the male compared to the female subjects studied by Laumann and
colleagues (1994). It was reported by about 35% of women aged 35 to 59 com-
pared with about 31 % of women aged 18 to 34 and about 22% of men aged 50
to 59 compared with about 16% of men aged 18 to 49. A marked increase in
prevalence with age in women was found by Hallstrom and Samuelsson (1990).
Absence of desire was reported by 4%,3%,9%, and 21 %, and at 6-year follow-
up by 0%, 7%, 16%, and 29% of their representative sample of partnered
Swedish women finally aged 44,52,56, and 60. Prevalence of impaired sexual
interest increased with age in the partnered English women who attended two
general practices who were studied by Hawton and colleagues (1994), from 4%
in those aged 35 to 39 to 28% of those aged 50 to 59. Of the American advan-
taged subjects studied by Pfeiffer and colleagues (1972) and Brecher (1984), no
sexual interest was reported by 0%,3%, and 11% of men and 7%,25%, and
50% of women aged 46 to 50, 51 to 60, and 61 to 71, respectively, in the former
study, and by 1%,2%, and 8% of the men and 4%,10%, and 18% of the
women in their 50s, 60s, and 70s, respectively, in the latter study. Lack of in-
terest was reported by 25 % of women but not mentioned as one of their six
most common problems by men in an American advantaged group aged 80 to
102 investigated by Bretschneider and McCoy (1988). Sexual interest was con-
sistently higher in the advantaged men than those of the same age more repre-
sentative of the normal population. A similar trend for women was present in
the studies of Bretschneider and McCoy and Brecher (1984) but not that ofPfeif-
fer and colleagues (1972).
Laumann and colleagues (1994) found that the percentage of women re-
porting climaxing too early declined with age from 14% ofthose 18 to 24 to 8%
of those 55 to 59, whereas percentage of men reporting this increased with age
from 27% to 35% for the same age groups. Brecher (1984) reported statements
of a number of men 50 to 70 years and greater that they had ceased to suffer
from premature ejaculation. but commented that aging was not always a cure
for the condition and that "a few of our old men continue to be afflicted with it"
(p. 324). Only 3 of the 188 advantaged men aged 60 to 79 in Martin's study
(1981) reported that premature ejaculation was recently a problem.
Percentages of women and men surveyed by Laumann and colleagues
(1994) reporting anxiety about performance reduced markedly with age, from
18 to 4 of women and 21 to 11 of men in the age ranges 18 to 24 to 55 to 59 re-
spectively. In advantaged subjects aged 80 to 102 fear of poor performance was
not one of the six most common sexual problems reported by women, but it was
the most common in men, being reported by 37% (Bretschneider & McCoy.
1988). The much higher prevalence in the advantaged men was presumably re-
lated in part to the prevalence of erectile dysfunction, reported by 33%, com-
pared with 21 % of the 55-59-year-old men in Laumann and colleagues' (1994)
study. However, the marked difference in prevalence of performance anxiety
suggests that many more advantaged men are concerned about their reduced
function than are those representative of the normal population. This behavior
is consistent with that of Martin's (1981) subjects, which led him to the conclu-
sion referred to earlier, that many older men were comfortable with their re-
duced level of sexual activity.
Laumann and colleagues (1994) found prevalences of pain during sex and
not finding sex pleasurable showed consistent and marked decreases with age
in women, from 21 % to 8% and 27% to 16% respectively, ofthose aged 18 to
24 and 50 to 59. Hawton and colleagues (1994) reported a contrary trend in En-
glish women seeing general practitioners as to prevalence of not finding sex
pleasurable. The percentage who considered making love with a partner un-
pleasant on all occasions in the preceding 3 months increased with age from
1.1 % ofthose aged 35 to 39 to 11.3% of those aged 55 to 59. Over the ages of 18
to 59 the men in the study by Laumann and colleagues (1994) reported preva-
lences of pain during sex ranging from 1.9% to 5.7% and of not finding sex
pleasurable ranging from 5.6% to 9.7%. Neither prevalence showed a clear re-
lationship with age, although that of pain during sex was highest in the
youngest and oldest groups: 5.7% ofthose aged 18 to 24 and 4.6% in those aged
55 to 59. These two sexual dysfunctions do not appear to have been investi-
gated in studies of subjects above average in health.
It would appear that in subjects of the same age superior health may result
in lower incidence of orgasmic difficulties and, particularly in men, of loss of
sexual interest, but not of erectile dysfunction or lack of vaginal lubrication. It
does not prevent the incidence of all these dysfunctions increasing with age. A
direct relationship between poor health and the prevalence of sexual dysfunc-
tions was reported by Laumann and colleagues (1994). Seven percent of their
subjects aged 18 to 24 but 25% ofthose aged 55 to 59 reported their health to be
fair or poor. Those who reported this were much more likely also to report hav-
ing at least one of the seven sexual problems investigated. The relationship was
much stronger in men. Although women in fair or poor health reported higher
prevalence of all the problems than did women in excellent health, the differ-
ence was never more than twice as great. Few men reported poor health, but
prevalence of all the problems in those with fair health was up to four times
greater than those in excellent health. Hence, although prevalence of erectile
dysfunction or lack of vaginal lubrication was not found to be reduced in sub-
jects selected for greater health compared with people of the same age more
representative of the normal population, within the latter group a clear re-
lationship was found between the subjects' self-assessed health status and the
prevalence of both dysfunctions.
Sexual Dysfunctions and Sexual Satisfaction
The lack of relationship between sexual dysfunctions and sexual satisfaction

found in younger adults (McConaghy, 1993) also has been found in older subjects.
Schiavi and colleagues (1990) commented that advantaged 45-74-year-old men in
stable relationships, although they reported decrease in several functional
dimensions of male sexuality with age, also reported that their enjoyment of
marital sex and their satisfaction with their own sexuality did not change. Male-
partnered women aged 35 to 59 seeing two general practitioners in England re-
ported reduced frequency of orgasm but no decrease in their sexual satisfaction
with increasing age; strangely, this occurred despite the fact that increasing age
was associated with a .higher percentage of women reporting more occasions on
which sexual activity was unpleasant and fewer occasions on which it was en-
joyed (Hawton et a1., 1994). As many women at times prefer tender caressing to
intercourse (McConaghy, 1993), the satisfaction of the older women may have
been maintained by the caressing accompanying their sexual activity. Multivari-
ate analysis revealed that their marital adjustment made the major contribution to
their reports of sexual activity being pleasant and of sexual satisfaction. Brecher
(1984) found that 90% of husbands and wives 50 years of age and over who were
having intercourse, and 67% of wives and 71 % of husbands who were not, re-
ported being happily married; this was also reported by 92% of subjects who ex-
perienced orgasm in all or almost all sexual relationships compared with 83% of
those who did so on half or fewer occasions. The increased prevalences of having
intercourse and of reaching orgasm could have been a result of, rather than a con-
tribution to, the happy marriage. A somewhat stronger correlation with marital
happiness was found with being comfortable discussing sexual matters with
spouses. Of men and women who reported this, 92% were happily married com-
pared with 64% of wives and 70% of husbands who did not.
Laumann and colleagues (1994) did not report the relationship of the pres-
ence of sexual problems with sexual satisfaction, but in what could appear a
contrasting finding, they found strong relationships between the presence of the
sexual dysfunctions they investigated and feelings of being mainly unhappy.
However, there also was a strong relationship between subjects' levels of health
and happiness, so in view of the correlations between sexual dysfunctions and
poor health, health rather than the dysfunctions could have been responsible
for the unhappiness of subjects with sex problems.
Reluctance to seek help for sexual dysfunctions found in younger adults

(McConaghy, 1993) is also evident in studies of older people. Of men attending
a medical outpatient clinic, 401 of 1,080 admitted on questioning to having erec-
tile dysfunction (Slag et aJ., 1983 J. Prior to the inquiry only 6 had been identified
as having the dysfunction. The authors commented that subjects were reluctant
to call attention to the dysfunction but were eager to discuss and seek evaluation
for it when the physicians broached the topic. In fact, only 188, slightly less than
half, accepted the offer of evaluation. Their mean age was 59 years, comparable
with the mean of 56.5 years ofthe functional men; the mean age of those who re-
fused evaluation was 67 years. Of the 60-79-year-old male volunteers of a Balti-
more study of aging who had potency problems. only 10% sought medical
advice for the condition (Martin, 1981). Martin considered that the majority were
uninterested, due to low sexual motivation. They were virtually free from per-
formance anxiety, feelings of sexual deprivation, and loss of self-esteem. Solstad
and Hertoft (1993) administered a questionnaire to 439 Danish men aged 51,
whom they considered representative of the population; 20% reported occa-
sional to total erectile dysfunction with intercourse. When 100 were subse-
quently interviewed a further 7 reported the dysfunction more than
occasionally; 32 reported other sexual problems. However, of the total of 39 of
the 100 interviewed who reported problems, only 7% considered them abnor-
mal for their age and only 5% planned to consult a therapist. Of 142 English
women, 87 of whom were 50 years old and older. who reported impaired sexual
interest, vaginal dryness. infrequency of orgasm, or dyspareunia or a combina-
tion, only 32 considered they had a sexual problem, as did a further 10 of 294
with no dysfunctions (Osborn et aJ., 1988). Of the 42 who considered they had a
problem. 16 said they wished treatment if it was available. One was receiving it.
A factor increasing older people's sexual satisfaction could be what Brecher
(1984) termed the "empty nest honeymoon": the experiences of older couples
who became more free in their sexual activity when their children left home. He
found that 87% of couples without, as compared with 80% of those with de-
pendent children living at home, reported being happily married. Anecdotal ev-
idence indicated that both men and women continued to go to considerable
lengths to conceal their sexual activity from children into their adulthood. He
found little evidence of the "empty nest syndrome" invoked by health profes-
sionals to explain a variety of problems experienced by women whose children
have left home. However. before the syndrome is dismissed as another example
of faulty post hoc. ergo proper hoc reasoning, the possibility needs to be con-
sidered that Brecher's conclusion may be relevant only to the subjects he stud-
ied who were above average in education, health, and income. Less educated
women might obtain more of their satisfaction in life from their children and
hence experience more dissatisfaction when they leave home.
Etiology
Most elderly men seeking help for sexual difficulties do so for erectile dif-
ficulties. Elderly women rarely seem to seek help directly for sexual problems,
except as part of menopausal symptoms.
The 401 (34%) of 1,080 men who reported erectile dysfunction (Slag et a1.,
1983) would appear to be one of the most representative samples studied, hav-
ing been selected from those attending a medical clinic, and so not limited to
those presenting with the dysfunction. The mean ages of both the functional
and dysfunctional men were 61 years, so that percentage impotent was less
than double the approximately 20%, which would be expected in a representa-
tive sample of the normal population of this age (McConaghy, 1993). In the 188
who agreed to evaluation, hormonal abnormalities were the most common or-
ganic cause, primary or secondary hypogonadism in 19%, diabetes in 9%, and
hyperprolactinaemia, or hyper- or hypothyroidism, in 10%. Medications were
considered responsible in 25%, those most often implicated being diuretics,
antihypertensives, and vasodilators. Neurological causes were diagnosed in
7%, urological causes in 6%, and other medical conditions in 4%. Fourteen
percent were considered to have a psychological cause, and no cause was found
in 7%. The majority of the men with erectile dysfunction reported a gradual on-
set of the condition, with continuance of their normal libido, consistent with
the evidence discussed earlier of the persistence of sexual interest in most older
men. Nearly half of the dysfunctional men without diabetes or hyperprolacti-
naemia were having erections either in relation to sexual stimulation or spon-
taneously, but they were of inadequate turgidity for coitus. Slag and colleagues
found that a number of patients who experienced erectile dysfunction with
medications had stopped them, but were hesitant to tell their physician why
they had, and hence were often considered noncompliant.
Absence of any cases of erectile dysfunction specifically attributed to vas-
cular pathology in the study of Slag and colleagues (1983) appears inconsistent
with the significance attributed to this condition by other workers. They did re-
port that 81 % of the dysfunctional men as compared to 54% of the functional
men had diagnosed hypertension prior to the study. Apparently these investi-
gators did not evaluate their subjects' penile blood pressure index (PBI) and the
ratio of their penile to brachial systolic blood pressure. Gewertz and Zarins
(1985) considered that vascular occlusive disease was too frequently over-
looked as a cause of erectile dysfunction in middle-aged and older patients, and
recommended PBI screening to avoid this omission. In men having intercourse
with their wives at the age of 70, hypertension was present in 10 and hyper-
triglyceridemia in 2 of the 21 who ceased intercourse, and in 1 and 0, respec-
tively, of the 25 who continued the activity, over the following 5 years (Persson
& Svanborg, 1992). The authors pointed out that both conditions were risk fac-
tors for arterial disease.
In an investigation of 121 male veterans aged 60 to 85 years (mean age 68)
who sought treatment, Mulligan and Katz (1989) found that 87% had a dis-
cernible organic cause and 9% a psychogenic cause. Coexistence of neurological
and vascular disorders, present in 30%, was the most frequent organic cause.
Vascular disease alone was responsible for 21 %, diabetic neuropathy for 17%,
and nondiabetic neuropathy for 10%. Hypogonadism was present in 2.6%. The
much lower incidence of hormonal causes apart from diabetes in these subjects,
compared with those evaluated by Slag and colleagues (1983), could be related
in part to the latter subjects' being more representative of the total population of
men with erectile dysfunction. Differences in diagnostic criteria could also be in-
volved. Mulligan and Katz (1989) stated that they diagnosed hypogonadism only
when a therapeutic response to testosterone was present. Salmimies, Kockott,
Pirke, Vogt, and Schill (1982) found that the threshold oftotal testosterone in hy-
pogonadal men below which sexual function is impaired varied between 2 and
4.5 ng/ml; some with levels of above 3 ng/ml showed reduced frequency of erec-
tions and ejaculations, which then increased in response to administration of
testosterone. Korenman and colleagues (1990) reported that 267 men with erec-
tile dysfunction (mean age 64) who attended a sex dysfunction clinic, 39% were
hypogonadal based on bioavailable testosterone levels below 2.3 nmol/L, and
12% were hypogonadal based on total testosterone levels lower than 10.5
nmol/L (3 ng/ml). A higher percentage of a healthy potent control group of men
aged 65 were hypogonadal on both criteria. The authors concluded that both
hormonal hypogonadism and impotence were common but independent in
older men, consistent with the evidence that the level of testosterone to maintain
erectile function is markedly below that necessary to maintain sexual interest
(McConaghy, 1993). They did not, however, assess their subjects' level of sexual
interest. Studies of representative population samples are necessary to deter-
mine the relationship of testosterone levels with age and erectile dysfunction.
In addition to diseases specifically impairing sexual functioning, those as-
sociated with pain, or that produce debility, anxiety, or depression, are likely to
reduce sexual interest significantly. Wabrek and Burchell (1980) found that, of
men hospitalized for myocardial infarction, most of whom were aged 50 to 69,
two thirds reported a sexual problem, predominantly erectile dysfunction, prior
to the infarction. Possibly due to the belief then current that almost all sexual
problems were psychologically caused, the authors considered that the infarc-
tion was secondary to the stress of the erectile dysfunction, rather than that the
dysfunction was due to associated vascular disease and medication. Dhabu-
wala, Kumar, and Pierce (1986) found that 42% of 50 mostly elderly men who
had suffered infarction 2 years to 6 months previously reported erectile dys-
function, defined as failure to have intercourse within the last 2 years despite
attempts; 48% of a control group matched for age, hypertension, diabetes, and
smoking reported the same complaint, indicating that infarction of itself was
not a significant cause of the dysfunction.
Though pointing out the high incidence of hysterectomy in older women,
at that time 43% in women aged 70, Brecher (1984) found only a small reduc-
tion of sexual activity and enjoyment in his subjects who had undergone it, in
comparison with those selected to be of good health. This was also true of those
who had both ovaries removed, many of whom were not taking replacement es-
trogen, and of those who had undergone mastectomy. Thirteen percent of his
male subjects, including 42% of those aged 80 or over, had undergone prostate
surgery, either transurethral resection or prostatectomy. Following surgery 83%
reported being sexually active and 81 % reported high enjoyment of sex com-
pared to 94 % and 87% of the healthy comparison group. Brecher did not report
whether the nature of the sexual activity had changed following surgery, but did
record sequelae of erectile dysfunction and lack of ejaculation.
Segraves and Segraves (1992) reviewed the literature reporting associa-
tions of erectile dysfunction with a wide variety of pharmacological agents and
drugs of abuse. They pointed out the paucity of adequately designed studies to
establish these associations but considered independent studies of large num-

bers of men experiencing the problem made the association highly probable.
Brecher (1984) found in his subjects that, compared with those selected to be
in good health, both men and women on antihypertensive medication reported
lower levels of sexual activity and of enjoyment of sex. Riley, Steiner, Cooper,
and McPherson (1987), in a study of subjects attending a hypertension clinic,
concluded that treated hypertensive men had a higher incidence of both erec-
tile and ejaculatory dysfunction than untreated men, but that treatment did not
have a significant effect in women on the prevalence of arousal or orgasmic
dysfunction. They commented that high prevalence of dysfunctions in women
may have obscured such an effect. Segraves and Segraves (1992) considered
that, of the commonly prescribed hypotensive agents, propranolol, methyl-
dopa, clonidine, and guanethidine were highly likely, and prazosin, hy-
dralazine, atenolol, labetalol, and especially captopril unlikely to produce
erectile dysfunction. Of the psychiatric drugs, sexual problems were more
common with most antipsychotics, particularly thioridazine, and tricyclic an-
tidepressants, particularly amitriptyline and clomipramine, but less so with
haloperidol, desipramine, carbamazepine, monoamine oxidase inhibitors, and
minor tranquilizers. However, in their controlled study Harrison, Rabkin, and
Ehrhardt (1986) found that monoamine oxidase inhibitors produced a high in-
cidence of sexual problems compared to placebo in depressed patients. These
conclusions are clearly relevant to the treatment of the large number of elderly
subjects with hypertension or depression.
There appears to be little evidence from surveys of impotent men to sup-
port the commonly reported clinical observation that alcohol is an important
contributing factor (McConaghy, 1993). Slag and colleagues (1983) found preva-
lence of alcoholism in older men evaluated for erectile dysfunction was far
lower than in functional men, but similar to that in the general population. Of
the representative married men who were having intercourse with their wives
at the age of 70, the 25 who were continuing to have intercourse 5 years later in-
dicated more heavy alcohol use than the 21 who ceased intercourse over this
period due to factors in themselves (Persson & Svanborg, 1992).
A possible role for constitutional factors influencing prevalence of sexual
dysfunctions independent of aging was suggested by Martin's (1981) finding in
socioeconomically advantaged married men aged 60 to 79 years. In relation to
level of sexual activity throughout their lives, 75 % percent of the least active,
46% of the moderately active, and 19% of the most active were partially or to-
tally impotent; 21 % of the least active as compared with 8% of the most active
had experienced long-term problems with premature ejaculation.
Investigation of the etiology of older women's reduced sexual interest and
frequency of orgasm has largely focused on the relationship of these symptoms
to menopause. Plotting levels of sexual interest of 562 partnered Swedish
women aged 38, 46, 50, and 54 in relation to whether they were in the pre-
menopausal, perimenopausal, or early or late postmenopausal phases, Hall-
strom (1979) found a strong and significant association between these phases
and decline in sexual interest; there were only small differences in decline with
age when menopausal phases were held constant. Comparison of women seeing
two general practitioners in Oxford, England, revealed that 57% of 34 post-
menopausal and 33% of 34 age-matched premenopausal women reported low

sexual interest in the past year (Hawton et aJ., 1994). However, the difference
failed to reach statistical significance, and the authors decided that their finding
was somewhat at variance with that of Hallstrom (1979)-a likely Type 2 error
resulting from the inappropriate significance attached to statistical significance
when subject numbers are small. Twenty-nine percent of the postmenopausal
but none of the premenopausal women reported never enjoying sexual activity
(a significant difference). N. 1. McCoy and Davidson (1985) in a longitudinal
study investigated 16 perimenopausal women aged 45 to 54 from 22 months be-
fore to 23 months after their final cycles. Following menopause the women had
fewer sexual fantasies and less vaginal lubrication during sex, and were less sat-
isfied with their partners as lovers. N. McCoy, Cutler, and Davidson (1985) re-
ported a close association in 43 perimenopausal women, probably including
many of those in the study discussed, between increasing irregularity of men-
strual cycles, hot flushes, declining estradiol levels, and declining frequency of
intercourse. They suggested that discomfort from hot flushes and other symp-
toms may reduce interest in sexual activity, that reduction of estrogens associ-
ated with the menopause may result in hot flushes and reduced sexual interest,
or that sexual activity may protect against hot flushes by releasing hormones.
Myers and Morokoff (1986) found that vaginal lubrication and sexual arousal
to an erotic film to be significantly greater in premenopausal women and
postmenopausal women receiving replacement estrogen compared with post-
menopausal women who were not. Degree of both responses to the film were
significantly related to their estradiol levels. The sexual functioning ofhysterec-
tomized women receiving estrogen replacement was higher than those not re-
ceiving it, 94% reporting being sexually active compared with 72% not taking
estrogen (Brecher, 1984). The sexual functioning of those taking estrogen was
equivalent to that of women with superior levels of health. Brecher reported
anecdotal evidence from six women of an association between cessation of es-
trogen replacement and occurrence of atrophic vaginitis with dyspareunia and
remission of these conditions with resumption of estrogen. Of all the post-
menopausal women in his study, 408 were taking estrogen and 1,356 were not.
Sexual activity was reported by 93% of the former and 80% of the latter; other
measures of sexual functioning were also greater in the women taking estrogen.
Brecher pointed out that women taking estrogen were slightly younger but he
did not attempt statistical control of this major variable.
There is no general agreement as to whether vasomotor symptoms (hot
flushes and sweating) and atrophic vaginitis and associated reduction in vaginal
lubrication are the only true symptoms of menopause and that they result from
fall in estradiol levels. Workers holding this view consider that depression and
reduced sexual interest, when present in women of menopausal age, are sec-
ondary to these symptoms or to stereotyped beliefs concerning the effects of
menopause; an alternative view is that atrophic vaginitis results from reduced
sexual activity which is associated with fall in androgen levels (McConaghy,
1993). Menopausal symptoms are related to the length oftime since menopause,
with vasomotor symptoms declining in severity, while genital symptoms such as
atrophic vaginitis worsen (Walling. Andersen. & Johnson, 1990). These authors
reviewed the literature on hormonal replacement therapy for postmenopausal
women but did not find convincing evidence of a direct hormonal effect on the
women's sexual interest, consistent with the lack of evidence of a clear effect on
premenopausal women's sexuality of the fluctuations in hormonal levels ac-
companying the menstrual cycle (McConaghy, 1993).
There was no obvious change in the representative women studied by Lau-
mann and colleagues (1994) in prevalence of sexual dysfunctions around the time
of menopause apart from having trouble lubricating, which increased in those 45
and older. However, as discussed earlier, prevalence of sexual dysfunctions in
younger women in this study was very high compared to that in other surveys.
Prevalence of pain during intercourse in Laumann and colleagues' 18-59-year-old
female subjects declined consistently with age from 21.5% to 8.7%. It was low in
the representative partnered Swedish women aged 38, 46,50, and 54; 5% occa-
sionally, 1 % usually, and 2% always experienced external dyspareunia with sex-
ual intercourse (Hallstrom, 1979). Hawton and colleagues (1994) cited studies
indicating that gynecological symptoms other than those of major surgery and se-
rious disease had surprisingly little effect on women's sexual function, except for
an association of sexual dysfunctions with the psychological symptoms of pre-
menstrual syndrome and with stress incontinence. In their study of partnered
women, after controlling for age effects, they found positive relationships be-
tween reduced frequency of orgasm and number of physical premenstrual symp-
toms in all the women, and between rarely or never enjoying intercourse and
experienced hot flushes in the preceding month, in women aged 55 to 59.
MANAGEMENT
Assessment
As discussed earlier, only 6 of 401 medical outpatients with erectile dys-
function had informed their physicians concerning it, and when it was identi-
fied on direct questioning only 188 (mean age 59) accepted the offer of
evaluation. The mean age of those who refused evaluation was 67 years (Slag
et a1., 1983). Few men, aged 51 and 60 to 79 years respectively, identified in sur-
veys by Solstad and Hertoft (1993) and Martin (1981) as having the dysfunction,
intended to seek treatment. On examination, 142 of 436 English women mainly
50 had a sexual dysfunction; only 42 considered they had a sexual problem and
only 16 wanted treatment if it was available (Osborn et a1., 1988). If older peo-
ple's sexual dysfunctions are to be identified health professionals need to in-
quire directly about them. The findings of Slag and colleagues suggest that this
is uncommon. Patterson and Dupree (1994), in discussing the diagnostic inter-
viewing of older adults, stressed the importance of avoiding ageism, with its
tendency to overlook the mental health of these adults. They made no reference
to a need to investigate the sexual activity of older people. Rather than pointing
out the requirement for direct inquiry, they advised "do not hesitate to discuss
intimate data if presented" (p. 391). The finding of Solstad and Hertoft (1993)
that many more men reported sexual problems at interview than in a previously
administered questionnaire indicates some validity for direct inquiry in assess-
ing sexual problems in the elderly.
Physical examination and laboratory assessments are virtually routinely

carried out in elderly men with erectile dysfunction, as it is rarely situational
and hence purely psychogenically determined. Situational erectile disorder is
that occurring with some but not other partners, or with all partners but not in
private masturbation where no pressure to produce an erection is experienced.
Physical examination is indicated to exclude such conditions as Peyronie's dis-
ease and hypogonadism, and blood and urine screening to exclude diabetes, hy-
perprolactinaemia, and thyroid dysfunction. Karacan (1978) recommended
nocturnal penile tumescence (NPT) assessment of subjects with erectile dys-
function as he considered that if they showed erections during dream or rapid
eye movement sleep similar to those of normal men, their dysfunction was due
to a psychological, not an organic cause. The procedure was conducted in a
sleep laboratory over three consecutive nights. Men who showed erections were
awakened on the third night for them to assess the fullness and to have the
rigidity determined by the pressure necessary to produce buckling. Apart from
evidence questioning the validity of the procedure in men of all ages (Mc-
Conaghy, in press), Schiavi (1992) considered assessment of penile buckling to
be impractical in older subjects because of rapid penile detumescence on test-
ing. Adequacy of penile blood flow is commonly assessed by determination of
subjects' penile-brachial index (PBI), the ratio of the blood pressure in the pe-
nile arteries, commonly measured by Doppler ultrasound probe, and conven-
tionally measured blood pressure in the brachial artery in the arm. The reliance
of clinicians on NPT and PHI assessment of erectile dysfunction was questioned
by Saypol, Peterson, Howards, and Yazel (1983). They reported close agreement
between diagnoses of the psychiatrist and urologist based on clinical examina-
tion alone, and diagnoses based on the results of the patients' fasting blood
sugar and testosterone levels and their PBI and NPT assessments. They sug-
gested that expensive tests be reserved for patients whom the psychiatrist and
urologist disagree or cannot determine the diagnosis.
The pharmacological erection test is increasingly being used to assess pe-
nile vascular supply in erectile dysfunction. Vasodilating chemicals are in-
jected into one of the cavernous sinuses of the subject's penis. Development of
a rigid, well-sustained erection within 10 minutes indicates no major vascular
abnormality and, as assessed by Rigiscan, a slow onset indicates some degree of
arterial disease, and rapid detumescence, a venous leak (McMahon, 1994). The
Rigiscan is a portable monitoring instrument which continuously records fre-
quency, duration, and degree of penile tumescence using two strain gauge
loops, one placed at the base of the penis and one immediately behind the
glans. The loops tightened periodically, indenting the penis and providing a
measure of turgidity. If the subject does not develop an adequate erection fol-
lowing the injection, he may do so if he views an erotic video or employs man-
ual genital stimulation (McConaghy, in press). If vascular pathology is indicated
by the pharmacological erection test, further investigations are necessary to de-
termine its nature, generally commencing with evaluation of the cavernosal ar-
teries by color Duplex Doppler ultrasonography. If the equipment is available
this investigation is commonly carried out as part of the pharmacological erec-
tion test. Assessment of neurogenic factors producing erectile dysfunction is in-
dicated if there is a need to establish the etiology and the patient has a history
of diabetes, pelvic pathology, or radical prostatectomy, or if physical examina-

tion reveals the absence of the cremasteric, bulbocavernosal, or reduced lower
limb reflexes. Because investigations of organic factors producing erectile dys-
function require more expensive equipment and considerable experience in
interpretation. they are increasingly being taken over by urologists with an in-
terest in the treatment of erectile disorder.
Apart from the need for gynecological examination when dyspareunia or
symptoms indicative of atrophic vaginitis are present, physical and laboratory
examination of women with sexual dysfunctions are rarely carried out. As in
men, it is necessary to exclude illness, medication, or substances as responsible
for reduced sexual interest or decreased ability to reach orgasm. However, the
effects of neurological and vascular disease and of medications and drugs of
abuse on the sexuality of women are much more poorly documented. Hormone
studies are rarely considered in the absence of indications of hormonal imbal-
ance such as excessive hirsutism.
Treatment
The mean age of subjects in studies reporting treatment of sexual dysfunc-

tions is almost invariably in the 30s. It would seem that of subjects seeking
treatment for sexual problems older women present mainly to general practi-
tioners or gynecologists with physical rather than psychological symptoms,
mainly attributable to menopausal changes, and men present with erectile dif-
ficulties to urologists or specialized clinics. Hormone replacement with estro-
gen is the usual treatment for hot flushes and symptoms of atrophic vaginitis,
with the addition of a progestogen in nonhysterectomized women to prevent
the increased risk of endometrial hyperplasia and adenocarcinoma. Walling
and colleagues (1990) reviewed the various forms of administration of hormone
replacement and concluded that androgens may be of value to enhance sexual
desire when it has not responded to the estrogen-progesterone combination and
that this may be more likely in women who have undergone oophorectomy.
Organic factors almost invariably contribute to the erectile dysfunction of
older persons. It is not uncommon for men who present with this problem to a
urologist or sex therapist to report having received testosterone from a general
practitioner without having been investigated to determine that they were hor-
monally hypogonadal. LoPiccolo (1990) and Schwartz, Kolodny, and Masters
(1980) considered it was generally agreed that use of testosterone administra-
tion for sexual dysfunctions in men with normal levels of testosterone is with-
out value. In view of the finding of Salmimies and colleagues (1982) that
testosterone administration increased frequency of erections and ejaculations in
some men with serum testosterone levels of up to 4.5 ng/ml, it seems reasonable
to use this level as a cutting point below which to give men with sexual dys-
functions (particularly reduced sexual interest) a trial of testosterone adminis-
tration. In view of the evidence that reduction in total testosterone level at least
to 30% of the subjects' previous levels reduces sexual desire but not erectile
ability (McConaghy, 1993), administration oftestosterone is likely to be of more
than placebo value only in those few men with below-normal levels who com-
plain ofreduced sexual desire. Bruning, DeWolf, and Morgentaler (1995) con-
sidered that prostate needle biopsy should be mandatory prior to testosterone
therapy in hypogonadal men older than 60 and strongly encouraged in men 50
to 59. Such biopsy revealed presence of cancer in 6 men aged greater than 60
years, among 33 hypogonadal men aged 45 to 70, all of whom had negative dig-
ital rectal examination and a normal age-adjusted prostate specific antigen
(PSA) level. The authors speculated that the men's low androgen levels may
have falsely lowered their PSA into the normal range.
In the absence of treatable medical conditions or a psychogenic etiology,
men with erectile dysfunction are usually offered a choice of self-injecting a
chemical vasodilator into one of the corpora cavernosa of the penis or using a
vacuum constriction device prior to intercourse, or of having a penile implant.
It would seem that the first is becoming the most widely accepted initial treat-
ment, possibly because it was demonstrated in the assessment procedure to
produce a satisfactory and persistent erection. Althof and colleagues (1991) fol-
lowed up 42 men of mean age 54 years who commenced the procedure. The
improvement in quality of erections with foreplay and intercourse, sexual sat-
isfaction, frequency of intercourse, and coital orgasm reported at 1 month was
stated to be still present 1 year, but this seems to have applied only to those who
remained in treatment. Fifty-seven percent dropped out, with treatment inef-
fectiveness given as one reason. Comparable percentages of subjects dropping
out have been reported by other workers. In a study of 110 men, 34 of the 76
men who opted not to initiate or who discontinued treatment did so because of
loss of interest in sexual activity (Irwin & Kata, 1994). Althof and colleagues
(1991) expressed surprise at the poor patient acceptance of an efficacious and
relatively safe procedure, though pointing out that some subjects could not af-
ford the cost of approximately $100 monthly. As to the chemical employed,
prostaglandin El has been reported to produce a better erectile response (Siraj,
Bomanji, & Akhtar, 1990) and a much lower rate of prolonged erection (Meule-
man et aI., 1992) than papaverine. Pain at the injection site or during erection
was the most frequent side effect, occurring in 17% of subjects according to the
review by Linet and Neff (1994).
The vacuum constriction device (VeD) consists of an acrylic tube that the
subject places over his penis and presses against his body to produce an airtight
seal. He then evacuates air from the tube using an attached vacuum pump. The
resulting erection is maintained by transferring an elastic band from the base
of the acrylic tube to the base of the penis; the tube is then removed. Subjects
are instructed not to leave the band on for more than 30 minutes; it has loops at-
tached to facilitate its removal. Some subjects have difficulty learning to estab-
lish the essential airtight seal, some complain the procedure produces pain or
numbness in the penis, and some find it unacceptable as its use cannot be con-
cealed from the partner. L. A. Thrner and colleagues (1991) followed up 45 men
of mean age 60 years who had commenced its use a year previously. Six men
ceased because the erections produced were of insufficient rigidity, 2 because
of relationship difficulties, and 1 recovered. Using the VCD resulted in erec-
tions sufficient for intercourse on about 80% of occasions. The most frequent
side effects were blocked ejaculation in 40% and discomfort in 33%. Improve-
ment in quality of erections and sexual satisfaction were the most marked
responses reported by patients; subjective sexual desire and frequency of inter-

course increased at 1 month but then returned to baseline. Single men often felt
uncomfortable using the VCD with a new partner; unlike self-injection, its use
could not be concealed. Althof and colleagues (1992) reported that partners re-
ported equally good responses to both procedures when assessed at five periods
over a year. They felt more at ease in their relationships and characterized sex
as more leisurely, relaxed, and assured. Their negative reactions focused on the
lack of spontaneity and on hesitation about initiating sex. L. A. Turner and col-
leagues (1991) considered that the dropout rate of only 20% over a year of use
of the VCD compared very favorably with that following self-injection. How-
ever, review of other studies indicated that if the dropout rates of all men rec-
ommended use of VCDs or on whom it was tested are compared with the
dropout rates of all men who commenced self-injection programs, the rates are
approximately the same (McConaghy, 1996).
Men with erectile disorder not wishing or responding satisfactorily to use
of intracavernous injections or of VCDs may accept penile implantation of a
prosthesis. This can be a semirigid silastic rod which increases penile rigidity
but not its size, or a device which the subject can inflate by a pump placed in
the scrotum. Steege, Stout, and Carson (1986) concluded that about a quarter
of recipients had significant dissatisfaction with the procedure, complaining of
alterations in penile dimensions or in sensations during arousal or ejaculation.
There were no significant differences in relation to the type of implant and
90% would have the procedure again if confronted with the same therapeutic
choices.
Some men with erectile dysfunction of organic etiology who do not accept
self-injection, VCD, or penile implants can be helped by a cognitive-behavioral
psychotherapeutic approach emphasizing improved sexual communication
and employment of sexual activities not requiring a firm erection, possibly in-
cluding "penile stuffing"; this can be easier if the man lies in the supine posi-
tion. Counseling may be necessary for subjects with medical conditions that
impair their sexual functioning either through the associated anxiety or physi-
cal disability. Of men who received sexual counseling following myocardial in-
farction, 24% reported fear of resuming intercourse in the next 6 months
compared with 80% of men who were not counseled (Dhabuwala et a1., 1986).
The authors did not report whether there were differences in the number who
resumed intercourse. They stated that most of those counseled had been ad-
vised to resume sexual activity if they could climb one or two stairs without
symptoms. This is probably a misprint for one or two flights of stairs. Being able
to climb two flights of stairs was the criterion cited by Brecher (1984); those
who could not do so without suffering cardiac pain or shortness of breath were
advised to take their usual dose of nitroglycerine 15 to 30 minutes before en-
gaging in sex, advice that would seem more appropriate for those who reacted
with pain.
Schiavi and colleagues (1990) pointed out that many older couples contin-
ued to engage in satisfying intercourse in the face of significant decrements in
erectile function and suggested that it may be as important to focus attention on
attitudinal factors and coping strategies as on the mechanisms involved in erec-
tile capacity. Given the wealth of information concerning frequencies of sexual
activities in the elderly, it is disappointing that there is so little concerning the

communication between sexual partners and how they deal with the problems
connected with increase in frequency of men's erectile problems with age and
dependence of women's sexual activity on the presence of an active partner.
Evaluation of therapy aimed at reducing the dependence of men's self-esteem
on their ability to maintain erections and increasing their acceptance of sexual
activity not requiring this ability is also necessary. Althof and colleagues (1991)
noted that, of men prior to their use of intracavernous injections when inter-
course was not possible, it often led to sexual abstinence with a concomitant
loss of affectionate holding and touching. They added that the couple com-
monly expressed frustration by saying: "Why bother trying when you can't do
anything?" and that from the women's perspective restoration of potency led to
more generalized changes in the men's self-esteem that made it easier to be with
them. One woman was quoted as saying: "How the hell can a man feel when he
can't have sex? He becomes cranky and mean." The relationship between com-
fort with sexual communication and marital happiness found by Brecher (1984)
was referred to earlier. He quoted a 66-year-old husband as saying, "Most part-
ners go through life playing a guessing game. By the time they really know what
turns each other on, it's turn-off time" (p. 95).
SUMMARY
After middle age an increasing percentage of men and women cease part-
nered sexual activity with subsequent aging; the percentage of women doing so
is considerably higher than that of men ofthe same age. In those who continue
the activity, its frequency, duration, and enjoyment declines with age. Cessation
of coitus in women is commonly due to absence or inability of their partner,
and in men to their own inability. Married women 60 years or older are much
more likely to be sexually active than unmarried women of the same age; the
difference is much less in men, reflecting the much greater opportunity for un-
married older men than women to find a heterosexual partner. The evidence
suggests that few men and women adopt nonpenetrative partnered sexual ac-
tivity or solitary masturbation as substitutes for coitus; those masturbating,
however, may be continuing an earlier practice The sexual interest and activity
of socioeconomically and health advantaged subjects are greater than those of
subjects of similar age representative of the total population. The level of sexual
activity of elderly men and to a less consistent extent of elderly women has
been found to be related to the level in their early adulthood, suggesting that a
biological determinant may contribute. A weak relationship between older
men's levels of sexual activity and of testosterone has been found; evidence is
conflicting as to whether decline in testosterone levels with age found in rep-
resentative population samples occurs in those selected for good health.
Studies of the prevalence of sexual dysfunctions in the elderly are limited
and tend to use different diagnostic criteria. A representative Swedish town
population sample reported a much lower prevalence of dysfunctions in
women aged around 40 years than did a representative American population
sample; presumably related to this difference the Swedish women showed a
marked increase in prevalence of dysfunctions with subsequent age, whereas

American women showed little increase and for some dysfunctions a decrease
in their prevalence with age. Studies of less representative American samples
generally showed increases in prevalence of dysfunctions with age. Subjects of
superior health reported lower incidences than the less healthy of orgasmic dif-
ficulties and loss of sexual interest (particularly men), but not of erectile dys-
function or lack of vaginal lubrication. Sexual satisfaction was not related to
presence of dysfunctions, consistent with the significant number of subjects
with dysfunctions not wishing treatment. Sexual satisfaction was related to
couples' marital adjustment and communication.
Studies of the etiology of erectile dysfunction of elderly men varied in per-
centages that showed the organic causes of vascular or neurological pathology,
hormonal abnormalities, other illnesses, or medications. Dysfunctions of el-
derly women reported were mainly considered sequelae of menopause. Assess-
ment of sexual problems in older men and women requires direct inquiry;
without this they seldom report such problems to their health caregivers. Phys-
ical examination is usually required for both older men and older women with
dysfunctions, but laboratory tests are carried out almost exclusively in men.
Hormonal replacement therapy for women and men and the options of intra-
cavernous injections, vacuum constriction devices, and penile implants for
men with erectile dysfunction were discussed. Evaluation of attempts to en-
courage men not accepting these treatments to adopt nonpenetrative sexual ac-
tivities with their partners is needed.
REFERENCES
Adams, C. G., & Turner, B. F. (1985). Reported changes in sexual activity from young adulthood to
old age. Journal of Sex Research, 21, 126-141.
Althof, S. E., Thrner, L. A., Levine, S. B., Risen. C., Bodner, D. Kursh, E. D., & Resnick, M. (1991).
Sexual, psychological, and marital impact of self-injection of papaverine and phentolamine:
A long-term prospective study. Journal of Sex and Marital Therapy, 147. 101-112.
Althof, S. E., Turner, L. A., Levine, S. B. Kursh, E. D., Bodner, D., & Resnick. M. (1992). Through
the eyes of women-The sexual and psychological responses of women to their partner's treat-
ment with self-injection or external vacuum therapy. Journal of Urology, 147, 1024-1027.
American Psychiatric Association. (1994). Diagnostic and statistic manual of mental disorders (4th
ed.). Washington, DC: Author.
Bergstrom-Walan, M-B, & Nielsen. H. H. (1990). Sexual expression among 60-80-year-old men and
women: A sample from Stockholm. Sweden. Journal of Sex Research, 27, 289-295.
Brecher. E. M. (1984). Love, sex and aging. Boston: Little, Brown.
Bretschneider. J. G., & McCoy, N. L. (1988). Sexual interest and behavior in healthy 80- to 102-year-
olds. Archives of Sexual Behavior, 17, 109-129.
Bruning. C. 0., m, DeWolf, W. C.• & Morgentaler. A. (1995). Occult prostate cancer in hypogonadal
men? Urology Review. 3, 1.
Chambers, K. C., & Phoenix, C. H. (1982). Sexual behavior in old male rhesus monkeys: Influence
of familiarity and age of female partners. Archives of Sexual Behavior, 11, 299-308.
Christenson, C. V., & Gagnon, J. H. (1965). Sexual behavior in a group of older women. Journal of
Gerontology, 20, 351-356.
Dhabuwala, C. B., Kumar, A., & Pierce, J. M. (1986). Myocardial infarction and its influence of male
sexual function. Archives of Sexual Behavior, 15,499-504.
George, L. K., & Weiler, S. J. (1981). Sexuality in middle and late life. Archives of General Psychia-
try, 38, 919-923.
Gewertz, B. L., & Zarins, C. K. (1985). Vasculogenic impotence. In R. T. Segraves & H. W. Schoenberg
(Eds.), Diagnosis and treatment of erectile disturbances (pp. 105-113). New York: Plenum.
Hallstrom, T. (1979). Sexuality of women in middle age: The Goteberg study. Journal of Biosocial
Science (Supp. 6), 165-175.
Hallstrom, T., & Samuels son, S. (1990). Changes in women's sexual desire in middle life: The lon-
gitudinal study of women in Gothenburg. Archives of Sexual Behavior, 19, 259-268.
Harrison, W. M, Rabkin, J. G., & Ehrhardt, A. A. (1986). Effects of antidepressant medication on sex-
ual function: A controlled study. Journal of Clinical Pharmacology, 6, 144-149.
Hawton, K, Gath, D, & Day, A. (1994). Sexual function in a community sample of middle-aged
women with partners: Effects of age, marital. socioeconomic, psychiatric, gynecological, and
menopausal factors. Archives of Sexual Behavior, 232, 375-395.
Hegeler, S, & Mortensen, M. (1978). Sexuality and ageing. British Journal of Sexual Medicine, 16-19.
Hunt, M. (1974). Sexual behavior in the 1970's. New York: Dell.
Irwin, M. B., & Kata, E. J. (1994). High attrition rate with intracavernous injection of prostaglandin
El. Urology, 43, 84-87.
Johnson, A. M., Wadsworth, J., Wellings, K., Field, J., & Bradshaw, S. (1994). Sexual attitudes and
lifestyles. Oxford: Blackwell.
Karacan, I. (1978). Advances in the psychophysiological evaluation of male erectile impotence. In J.
LoPiccolo & L. LoPiccolo (Eds.), Handbook of sex therapy (pp. 137-145). New York: Plenum.
Kinsey, A. C., Pomeroy, W. B., & Martin, C. E. (1948). Sexual behavior in the human male. Philadel-
phia: Saunders.
Kinsey, A. C., Pomeroy, W. B., Martin, C. E., & Gebhard, P. H. (1953). Sexual behavior in the human
female. Philadelphia: Saunders.
Korenman, S. G., Morley, J. E., Mooradian, A. D., Davis, S. S., Kaiser, F. E., Silver, A. J., Viosca,
S. P., & Garza, D. (1990). Secondary hypogonadism in older men; Its relation to impotence.
Journal of Clinical Endocrinology and Metabolism, 71, 963-968.
Laumann, E. 0., Gagnon, J. H., Michael. R. T, & Michaels, S. (1994). The social organization of sex-
uality. Chicago: University of Chicago Press.
Leibman, S., Bachmann, G., Kemmann E., Colburn. D., & Swartzman, L. (1983). Vaginal atrophy in
the postmenopausal woman. Journal of the American Medical Association, 249, 2195-2198.
Lewontin, R. C. (1995a, April 20). Sex, lies. and social science. New York Review of Books, pp. 24-29.
Lewontin, R. C. (1995b, August 10). "Sex, lies, and social science": Another exchange. New York Re-
view of Books, p. 56.
Linet, O. I., & Neff, L. L. (1994). Intracavernous prostaglandin E(l) in erectile dysfunction. Clinical
Investigator, 72, 139-149.
LoPiccolo, J (1990). Sexual dysfunction. In A. S. Bellack, M Hersen & A. E. Kazdin (Eds.), Interna-
tional handbook of behavior therapy and modification (2nd ed., pp. 547-564). New York:
Plenum.
Marsiglio, W, & Donnelly, D. (1991). Sexual relations in later life: A national study of married per-
sons. Journal of Gerontology: Social Sciences, 46, S338-8344.
Martin, C. E. (1981). Factors affecting sexual functioning in 6G-79-year-old married males. Archives
of Sexual Behavior, 10, 399-420.
McConaghy, N (1993). Sexual behavior: Problems and management. New York: Plenum.
McConaghy, N. (1996). Treatment of sexual dysfunctions. In V. B. Van Hasselt & M. Hersen (Eds.),
Source book of psychological treatment manuals for adult disorders (pp. 333-373). New York:
Plenum.
McConaghy, N. (in press). Assessment of sexual dysfunction and deviation. In A. S. Bellack &
M. Hersen (Eds.), Behavioral assessment: A practical handbook (3rd ed.). Elmsford, New
York: Pergamon.
McCoy, N., Cutler, W., & Davidson, J. M. (1985). Relationships among sexual behavior, hot flashes,
and hormone levels in perimenopausal women. Archives of Sexual Behavior, 14, 385-394.
McCoy, N. L., & Davidson, J. M. (1985). A longitudinal study of the effects of menopause on sexual-
ity. Maturitas, 7, 203-210.
McMahon, C. G. (1994). Management of impotence part II: Diagnosis. General Practitioner, CME
Files, 2, 83-85.
Meuleman, E. J. H., Bemelmans, B. L. H, Doesburg, W. H., van Asten, W. N. J. C., Skotnicki, S. H., &
Debruyne F. M. J., (1992). Penile pharmacological duplex ultrasonography: A dose-effect study
comparing papaverine, papaverine/phentolamine and prostaglandin El.Journa1 of Urology.

148,63-66.
Mulligan, T., & Katz, P. G. (1989). Why aged men become impotent. Archives of Internal Medicine,
149,1365-1366.
Mulligan. T. & Moss. C. R (1991). Sexuality and aging in male veterans: A cross-sectional study of
interest. ability. and activity. Archives of Sexual Behavior, 20, 17-25.
Myers. L. S.• & Morokoff. P. ]. (1986). Physiological and subjective sexual arousal in pre- and post-
menopausal women and postmenopausal women taking replacement therapy. Psychophysi-
ology, 23, 283-292.
Osborn. M.• Hawton. K.• & Gath. D. (1988). Sexual dysfunctions among middle-aged women in the
community. British Medical Journal, 296, 959-962.
Patterson. R L.• & Dupree. L. W. (1994). Older adults. In M. Hersen & S. M. Thrner (Eds.). Diagnos-
tic Interviewing (2nd ed.• pp. 373-397). New York: Plenum.
Persson. G.. & Svanborg. A. (1992). Marital coital activity in men at the age of 75: Relation to so-
matic. psychiatric. and social factors at the age of 70. Journal of the American Geriatrics Soci-
ety, 40, 439-444.
Pfeiffer. E.• & Davis. G. C. (1972). Determinants of sexual behavior in middle and old age. Journal
of the American Geriatrics Society, 20,151-158.
Pfeiffer. E.• Verwoerdt. A. & Davis. G. C. [1972). Sexual behavior in middle life. American Journal of
Psychiatry, 128, 1262-1267.
Reiss. I. L. (1995). Is this the definitive sexual survey? Journal of Sex Research, 32, 77-85.
Riley. A. J.• Steiner. J. A.. Cooper. R. & McPherson. C. K. (1987). The prevalence of sexual dysfunc-
tion in male and female hypertensive patients. Sexual and Marital Therapy, 2, 131-138.
Salmimies. P.• Kockott. G.. Pirke. K. M.. Vogt. H. J.• & Schill. W. B (1982). Effects oftestosterone re-
placement on sexual behavior in hypogonadal men. Archives of Sexual Behavior, 11, 345-353.
Saypol. D. C.• Peterson. G. A.• Howards. S. S .• & Yazel. J. J. (1983). Impotence: Are the newer diag-
nostic methods a necessity? Journal of Urology. 130. 260--262.
Schiavi. R C. (1992). Laboratory methods for evaluating erectile disorder. In R C. Rosen & S. R
Leiblum (Eds.). Erectile disorders assessment and treatment (pp. 141-170). New York: Guilford.
Schiavi. R C.• Schreiner-Engel. P.• Mandeli. J.. Schanzer. H.• & Cohen. E. (1990). Healthy aging and
male sexual function. American Journal of Psychiatry, 147,766-771.
Schwartz. M. F.• Kolodny. R C.• & Masters. W. H. (1980). Plasma testosterone levels of sexually func-
tional and dysfunctional men. Archives of Sexual Behavior, 9, 355-366.
Segraves. R. T.. & Segraves. K. A. (1992). Aging and drug effects on male sexuality. In R C. Rosen &
S. R Leiblum (Eds.). Erectile disorders assessment and treatment (pp. 96-138). New York:
Guilford.
Seidman. S. N .• & Rieder. R O. (1994). A review of sexual behavior in the United States. American
Journal of Psychiatry, 151.330--341.
Sennett. R (1995. May 25). "Sex. lies and social science": An exchange. New York Review of Books,
p.43.
Siraj. Q. H.• Bomanji. J.• & Akhtar. M. A. (1990). Quantitation of pharmacologically-induced penile
erections: The value of radionuclide phallography in the objective evaluation of erectile
haemodynamics. Nuclear Medicine Communications, 11,445-458.
Slag. M. F., Morley. J. E.• Elson. M. K.• Trence, D. L.• Nelson. C. J.• Nelson. A. E.• Kinlaw. W. B.•
Beyer. H. S .. Nuttall. F. Q.• & Shafer. R B. (1983). Impotence in medical clinic outpatients.
Journal of the American Medical Association, 249,1736-1740.
Solstad, K.• & Hertoft. P. (1993). Frequency of sexual problems and sexual dysfunction in middle-
aged Danish men. Archives of Sexual Behavior, 22, 51-58.
Steege J. F.. Stout. A. I.. & Carson. C. C. (1986). Patient satisfaction in Scott and Small-Carrion pe-
nile implant recipients: A study of 52 patients. Archives of Sexual Behavior, 15, 393-399.
Tsitouras. P. D.• Martin. C. E.. & Harman. S. M. (1982). Relationship of serum testosterone to sexual
activity in healthy elderly men. Journal of Gerontology, 37, 288-293.
Thrner, B. F., & Adams, C. G. (1988). Reported change in preferred sexual activity over the adult
years. Journal of Sex Research, 25, 299-303.
Thrner. L. A.. Althof, S. E., Levine, S. B., Bodner. D. R, Kursh, E. D.• & Resnick. M. I. (1991). Exter-
nal vacuum devices in the treatment of erectile dysfunction: A one-year study of sexual and
psychosocial impact. Journal of Sex and Marital Therapy. 17, 81-93.
von Sydow. K. (1995). Unconventional sexual relationships: Data about German women ages 50 to
91 years. Archives of Sexual Behavior. 24, 271-290.
Wabrek, A. J., & Burchell, R C. (1980). Male sexual dysfunction associated with coronary artery dis-
ease. Archives of Sexual Behavior, 9, 69-75.
Walling, M.• Andersen. B. 1.. & Johnson, S. R (1990). Hormonal replacement therapy for post-
menopausal women: A review of sexual outcomes and related gynecologic effects. Archives of
Sexual Behavior, 19, 119-137.
Weizman. R, & Hart. J. (1987). Sexual behavior in healthy married elderly men. Archives of Sexual
Behavior, 16,39-44.
White, C. B. (1982). Sexual interest, attitudes. knowledge, and sexual history in relation to sexual
behavior in the institutionalized aged. Archives of Sexual Behavior, 11, 11-21.
CHAPTER 13
Sleep Disturbances in Late Life

CHARLES M. MORIN, FRANCE C. BLAIS,
AND VERONIQUE MIMEAULT
INTRODUCTION
Sleep disturbance is a prevalent problem in late life, affecting healthy seniors

as well as medically ill and cognitively impaired individuals. In addition to
normal age-related changes in sleep patterns, the increased incidence of health
problems and medication use, combined with some inevitable stressful life
events, place the older adult at increased risk for sleep disturbances. These
problems can take many forms, including sleeping difficulties at night, exces-
sive or undesired sleepiness during the day, and disruptive behaviors occur-
ring during the sleep period (e.g., nocturnal wandering). Although not all
changes in sleep patterns are noticeable or produce distress, severe and per-
sistent sleep disturbances are associated with impaired daytime functioning,
increased health care costs, and poorer quality of life for the affected individ-
uals and their families.
Reports of daytime fatigue, memory and concentration problems, and dys-
phoria are much more common among poor sleepers than good sleepers (Gallup
Organization, 1991). Although the magnitude of performance impairments are
mild and selective (Hart, Morin, & Best, 1996), sleep disturbances are often as-
sociated with psychological distress and, when left untreated, they may in-
crease the vulnerability to major depression (Ford & Kamerow. 1989). Poor
sleepers use health-related services more frequently than good sleepers, both
for sleep and other somatic problems (Mellinger, Balter, & Uhlenhuth, 1985).
Nocturnal behavioral disturbances (e.g., wandering) among demented patients
can cause a significant burden on caregivers, sometimes hastening placement of
the impaired person in nursing care facilities (Pollak, Perlick, Linsner, Wen-
ston, & Hsieh, 1990).
CHARLES M. MORIN, FRANCE C. BLAIS, AND VtaONlQUE MlMEAULT • Ecole de Psychologie, Universite
Laval, Cite Universitaire, Quebec, Canada G1K 7P4
273
274 Charles M. Morin et a1.
The higher incidence of sleep disturbances in elderly persons is paralleled

by increased use of sedative-hypnotic drugs. Surveys indicate that 7.4% of the
adult population, and 14% of those in the 69- to 79-year-old range, use either a
prescribed hypnotic or over-the-counter sleeping aids during the course of a
year (Mellinger et a1., 1985). These figures more than double in elderly patients
attending general medical practices, where an estimated 26% of women and
6% of men older than 65 take prescribed hypnotics (Hohagen et a1., 1994). The
large majority of long-term users (> 1 year) are older adults, particularly
women, with one study reporting that 38% were aged between 50 and 64 years
old and 33% were older than 65 (Mellinger et a1., 1985). Of a sample of com-
munity-dwelling subjects over 65,11 % reported using hypnotic drugs regularly
for more than 1 year and an additional 4% for more than 10 years (Morgan, Dal-
losso, Ebrahim, Arie, & Fentem, 1988). These estimates nearly triple among in-
stitutionalized elders (Morgan, 1987). Overall, 39% of hypnotic drugs are
prescribed for adults aged 65 or older, although they represent only 13% ofthe
population.
Despite their increased incidence and debilitating effects in late life, sleep
disturbances are often unrecognized by health care professionals and remain
untreated (National Institutes of Health [NIH], 1991). This chapter describes the
nature of sleep disturbances in late life, the main differential diagnostic issues
and assessment procedures to consider in their evaluation, and effective treat-
ment methods for their clinical management. In as much as insomnia is the
most prevalent sleep complaint among elderly persons, and the problem most
likely to be encountered by health care professionals, this chapter focuses pri-
marily on this condition.
TIlE NATURE OF SLEEP DISTURBANCES

IN LATE LIFE
The incidence of subjective sleep complaints increases across the life cy-
cles. Among older adults, as many as 40% report some sleep problems, frequent
awakenings, early morning awakenings, and undesired daytime sleepiness, and
many more suffer from undiagnosed sleep disorders (Morgan, 1987). In this sec-
tion, we describe some normal changes in sleep patterns and some of the most
common forms of sleep disorders in late life.
Age-Related Changes in Sleep Patterns
Several age-related changes in sleep patterns occur even in normal aging.

The amount of time spent awake or asleep and the proportion of time spent in
NREM and REM sleep stages change over the course of the life span (D. L. Bli-
wise, 1993; Dement, Miles, & Carskadon, 1982; Webb, 1989). The most signifi-
cant of these alterations involve a reduction of stages 3 and 4 (deep) sleep and a
corresponding increase in stage 1 (light) sleep (Feinberg, Koresko, & Heller,
1967). These changes are accompanied by more frequent and longer nocturnal
awakenings in older people (Webb & Campbell, 1980). Subjectively, they are ex-
Sleep Disturbances in Late Life 275
perienced as lighter and more fragmented sleep, and may account for the in-
creased prevalence of insomnia complaints in late life. The proportion of stage 2
sleep, which occupies about 50% of a night's sleep, remains fairly stable across
age groups. The amount of REM sleep is only slightly diminished in older age
relative to young and middle adulthood (20%-25%). The latency to the first
REM episode, which is used as a biological marker of depression, is shorter
among older than younger adults, and REM sleep is more evenly distributed
throughout the night (Reynolds, Kupfer, Taska, Hoch, Spiker, et al., 1985).
Contrary to a common belief, total sleep time is not significantly reduced
from middle age to late life; however, older adults spend more time awake in
bed to achieve comparable sleep durations. Consequently, sleep efficiency (the
ratio of sleep time to time spent in bed), rather than sleep need per se, is di-
minished in late life. When sleep from daytime napping (a common practice in
the elderly) is added to nocturnal sleep, the total amount per 24-hour period
remains fairly stable in late life. Thus, the sleep of healthy older people is char-
acterized by a reduction in sleep quality, not sleep duration. Sleep continuity is
impaired, as evidenced by more frequent and prolonged awakenings. Older
adults spend more time awake in bed, and sleep efficiency is correspondingly
diminished. Although it is important to distinguish between normative and
pathological changes in sleep patterns, insomnia is not an inevitable conse-
quence of aging, and many elderly people suffer from sleep disruptions that ex-
ceed these developmental changes (Morin & Gramling, 1989).
Insomnia
Insomnia is the most common form of all sleep disturbances across the life
span. It can involve problems initiating sleep, trouble staying asleep through
the night (with frequent and prolonged nocturnal awakenings), or premature
awakenings in the morning with an inability to return to sleep (Morin, 1993).
Between 9% and 12% of the adult population report chronic and troublesome
insomnia during the course of a year, and for 12% to 25% of people age 65 or
older, sleep difficulties occur on a regular, chronic basis (Ford & Kamerow,
1989; Hohagen et al., 1994; Mellinger et aJ., 1985). The nature of sleep com-
plaints changes with age. Older adults report primarily, although not exclu-
sively, difficulty in maintaining sleep, whereas trouble initiating sleep is more
commonly reported by younger adults. Subjective sleep complaints are more
prevalent among women than among men. Paradoxically, sleep laboratory
recordings indicate more impaired sleep and a higher prevalence of such sleep
disorders as sleep apnea and periodic limb movements among noncomplaining
older men (Reynolds, Kupfer, Tascka, Hoch, Sewitch, & Spiker, 1985).
The clinical significance of insomnia complaints is sometimes difficult to
gauge. Although sleep disturbance increases with aging, this is not a universal
phenomenon, and some of the changes in sleep parameters do not necessarily
lead to the subjective complaint of insomnia. Some older adults are distressed
about changes in their sleep patterns, others notice but do not complain about
these changes, and still others do not report any changes in their sleep patterns.
Discrepancies between one's current sleep patterns and one's expectations may
276 Charles M. Morin et al.
also contribute to an insomnia complaint (Morin & Gramling, 1989). Further

compounding this problem is the significant discrepancy between subjective
and EEG sleep parameters; poor sleepers overestimate sleep latency and under-
estimate total sleep time.
The diagnosis of insomnia is made when there is a subjective complaint of
difficulties initiating or maintaining sleep that is associated with marked dis-
tress and/or impairments of social or occupational functioning (American
Psychiatric Association, 1994). These criteria are further operationalized in out-
come research whereby insomnia is defined as a sleep onset latency or wake
after sleep onset greater than 30 minutes, with a corresponding sleep efficiency
lower than 85%; the problem must occur more than three times per week and
last 6 months or longer (Lacks & Morin, 1992). Insomnia can be a primary prob-
lem or it can be associated with medical, psychiatric, alcohol and substance
use, and other sleep disorders.
Other Sleep Disorders
Older adults are at increased risk for several sleep disorders other than in-
somnia. Obstructive sleep apnea is a breathing disorder characterized by a com-
plete or partial cessation of airflow during sleep, lasting from a few seconds to
a minute, followed by a brief awakening and a loud gasping for air (Guillem-
inault, 1989). These episodes may occur repeatedly through the night, causing
severe sleep fragmentation. Older adults with central rather than obstructive
sleep apnea may awake short of breath and develop secondary insomnia, as
they become fearful of going back to sleep. Sleep apnea is associated with ex-
cessive daytime sleepiness and cognitive impairments and it may aggravate car-
diovascular problems. Restless legs syndrome is a condition in which a person
experiences an unpleasant, creeping sensation in the calves, and an irresistible
urge to move the legs. Worse in the evening, this condition can significantly in-
terfere with sleep onset. A related condition, periodic limb movements, consists
of brief, stereotyped, and repetitive leg twitches or jerks during sleep (Mont-
plaisir & Godbout, 1989). These movements may occur up to several hundred
times a night, unknown to the sleeper. Some individuals with documented pe-
riodic limb movements are totally asymptomatic but, in severe cases, these
movements cause severe sleep fragmentation and daytime somnolence. These
three disorders can give rise to a subjective complaint of insomnia, excessive
daytime somnolence, or both. Their incidence increases with aging (Ancoli-
Israel, Kripke, Mason, & Messin, 1981), but patients are typically unaware of the
underlying conditions. Some of our data suggest that about one third of older
adults with a subjective complaint of insomnia are diagnosed with one of these
disorders after undergoing a sleep laboratory evaluation.
REM sleep behavior disorder, a condition seen almost exclusively in mid-
dle-aged and older men, is characterized by violent behaviors (e.g., punching,
kicking) while the person is asleep (Schenck, Bundlie, Patterson, & Maho-
wald, 1987). These behaviors arise from REM sleep, a period usually asso-
ciated with muscle atonia; vivid dream recall is reported if the person is
awakened from these episodes. Less prevalent than the other disorders just
described, little information is available on this condition. It may be drug in-

duced or associated with neurological disorders. Psychopathology is gener-
ally not a contributing factor.
Sleep in Depression
Difficulties initiating and maintaining sleep are extremely common in af-

fective disorders, with early morning awakening being one of the most classic
symptoms of major depression. The sleep of elderly depressive patients is also
characterized by REM sleep alterations, including a shortened latency to the
first REM sleep period, a longer first REM sleep period, an increase in percent-
age REM sleep, and more intense REM activity (i.e., frequency and intensity of
eye movements (Benca, Obermeyer, Thisted, & Gillin, 1992; Reynolds, Kupfer,
Taska, Hoch, Spiker, et a1., 1985). Although the specificity of these changes is
not always clear, some of them have been useful diagnostically to discriminate
depressed geriatric patients from demented and normal age-matched controls
(see the following discussion).
Sleep Disturbances in Dementia
The sleep patterns of patients with Alzheimer's disease (AD) are character-
ized by several impairments in sleep continuity and architecture (sleep stages;
D. L. Bliwise, 1993; Prinz et a1., 1982; Vitiello, Prinz, Williams, Frommlet, &
Ries, 1990). These include more interrupted sleep and time spent awake in bed,
resulting in a lower sleep efficiency; diminished stages 3 and 4 sleep (slow-
wave sleep) and increased stage 1 sleep. Sleep stages are also more difficult to
distinguish from one another as some of their distinctive EEG features become
less frequent and more blurred with the degenerative condition. These distur-
bances are similar to those seen in normal aging, but are significantly more pro-
nounced in AD patients. As AD is a degenerative disease of the central nervous
system (CNS), sleep disturbances appear quite early and their severity increases
with progression of the illness. REM sleep is relatively unaffected in the early-
stage of AD. However, as the disease progresses, the percentage of REM sleep di-
minishes (Prinz et a1., 1982), and a general slowing of EEG activity is noted
during wakefulness, resulting in more daytime sleepiness (Coben, Chi, Snyder,
& Storandt, 1990; Prinz et a1., 1982).
With advancing severity of AD, the sleep-wake cycle becomes increasingly
desynchronized, resulting in significant amounts of sleep during the day and
wakefulness at night. AD patients spend nearly 40% of their nighttime hours
awake and considerable time asleep during the day (Prinz et a1., 1982). One
study of AD patients in a residential care facility found that every hour of the
day was characterized by some micro-sleep episodes and that every hour of the
night was perturbed by some wakefulness (Jacobs, Ancoli-Israel, Parker, &
Kripke, 1988). Daytime sleep is of poor quality, however, consisting almost ex-
clusively of stages 1 and 2 sleep, and does not compensate for the nighttime
losses of slow-wave sleep (Vitiello, Bliwise, & Prinz, 1992).
About 20% of AD patients residing at home show some evidence of sun-

downing, a condition that is characterized by exacerbation of disruptive behav-
iors, agitation, confusion, and disorientation near the time of sunset or at night
(D. 1. Bliwise, Yesavage, & Tinklenberg, 1992). Typical behaviors reported by
family members include wandering (often outside the house), turning on
kitchen appliances, and watching television or listening to the radio at high vol-
umes (D. L. Bliwise, 1993). Sun downing can be a very distressing feature of
dementia and cause a significant burden for families and caregivers (Gallagher-
Thompson, Brooks, Bliwise, Leader, & Yesavage, 1992); it may be the single
most important factor precipitating institutionalization of demented patients
(Pollak et al., 1990; Rabins, Mace, & Lucas, 1982; Sanford, 1975). Families are
usually able to manage and cope with the agitation, disorientation, inconti-
nence, and other disruptive behaviors occurring during the daytime hours.
However, when they cannot get some rest at night, the burden may simply be
too intense for them to keep the older person at home.
Extensive research has been conducted with depressed and AD patients in
the hope of identifying sleep abnormalities that might serve as early biological
markers or provide indices for the differential diagnosis between dementia and
depression in geriatric patients. Compared with normal aging, both conditions
have impaired sleep continuity and reduced sleep efficiency. However. some
features appear to discriminate between depressed and demented patients:
sleep continuity (e.g., greater sleep fragmentation and early morning awakening
in depressed than in AD patients), sleep architecture (e.g., greater proportion
of REM sleep in depressed patients but greater loss of NREM transient stage 2
sleep features in demented patients), and first NREM-REM sleep cycle (e.g.,
shorter REM sleep latency in depressives) (Benca et al., 1992; D. 1. Bliwise et
a1., 1989; Reynolds, Kupfer, Taska, Hoch, Spiker, et al., 1985; Reynolds et a1.,
1988; Vitiello et a1., 1990).
COMMON CAUSES OF SLEEP

DISTURBANCES IN OLDER PERSONS
Disturbed sleep can be a symptom of numerous conditions, including med-

ical, psychiatric, and other sleep disorders. Older adults with sleep disturbances
thus represent a very heterogeneous group. The following section outlines some
important issues to consider in the evaluation and differential diagnosis of geri-
atric sleep disturbances.
Medical Factors
Two thirds of the elderly over age 65 suffer from one or more chronic med-
ical conditions and many ofthose can interfere with sleep (Regenstein, 1980).
Almost any condition producing pain (e.g., arthritis) or physical discomfort in-
terferes with sleep, as does shortness of breath in congestive heart failures and
respiratory diseases (e.g., chronic obstructive pulmonary disease [COPD]). All
forms of degenerative neurological diseases, including the different dementias,
disrupt the normal sleep-wake cycles. Several medications prescribed for
health problems may disrupt sleep: bronchodilators (e.g., theodur), steroids

(e.g., prednisone), and some antihypertensives (e.g., propanolol). Diuretics may
cause frequent nocturia and sleep interruptions. Some psychotropic medica-
tions can also disrupt sleep. Among those are some of the SSRI antidepressants
(e.g., fluoxetine) and the MAO inhibitors. Sedative-hypnotics can also produce
a form of "iatrogenic insomnia." Caffeine and nicotine, both CNS stimulants.
produce fragmented and lighter sleep. Alcohol. a CNS depressant, may facili-
tate sleep onset but it interferes with sleep maintenance.
Psychological Factors
There is a high rate of comorbidity between sleep and psychiatric disor-

ders in the general population, with an estimated 35% to 44% of adults with a
primary complaint of insomnia receiving a psychiatric diagnosis (mostly
affective and anxiety disorders; Buysse et aJ., 1994; Morin & Ware, 1996). The
relationship of insomnia to psychopathology in late life is more equivocal.
Some cross-sectional data suggest that insomnia is not as strongly associated
with psychopathology in older adults as in younger people (N. G. Bliwise, Bli-
wise, & Dement, 1985; Roehrs, Lineback, Zorick, & Roth, 1982). Self-described
older insomniacs tend to report higher levels of depression and anxiety symp-
tomatology compared with good sleepers, but the severity of those symptoms
does not necessarily reach clinical threshold (Morin & Gramling, 1989). Older
adults are faced with some inevitable life events, such as retirement, deterio-
rating health, and the death of a spouse or friends, all of which can cause mood
and sleep disturbances.
When insomnia is severe and persistent over time, it tends to be more
strongly associated with depression (Ford & Kamerow, 1989; Hohagen et aJ.,
1994). In a longitudinal study of sleep and mood disturbances in 264 persons
aged 62 to 90 years over a 3-year period (Rodin, McAvay, & Timko, 1988), de-
pressed affect was positively correlated with sleep disturbances, even after con-
trolling for age, gender, and health status. The probability of reporting moderate
to severe sleep difficulties increased with the number of interviews at which a
subject was categorized as depressed. Early morning awakening was the sleep
problem most consistently related to depressed mood. A decrease in depressive
symptomatology over time was associated with a corresponding reduction in
early morning awakening. In a longitudinal study oflate-life depression in 1,577
community-resident elderly persons (Kennedy. Kelman, & Thomas, 1991), sub-
jects whose depressive symptoms persisted over a 2-year period (n = 97) were
compared with those whose symptoms remitted over the same interval (n = 114).
Subjects with persistent depressive symptoms tended to be older, experienced
declining health, and reported more sleep disturbances, suggesting that persis-
tent sleep disturbance may prevent or delay recovery from depression. Collec-
tively, these findings suggest that the presence of insomnia at a given time is not
a reliable indicator of psychopathology in elderly persons; however, severe and
persistent sleep disturbance is more reliably associated with mood disturbances,
particularly depression. There is not necessarily a direct cause-and-effect rela-
tionship, however, as mood disturbances may simply conveyor represent a
by-product of chronic insomnia rather than being its primary determinant.
Coexisting sleep and psychological disturbances may require separate therapeu-

tic attention (Bootzin, Engle-Friedman, & Hazelwood, 1983).
Circadian Factors
The basic rest-activity cycle, along with sleep and wakefulness, is governed
in large part by circadian principles. Their cyclic nature over the 24-hour pe-
riod is regulated by both an endogenous biological clock and by environmental
time markers. Of the several biological functions that are also regulated by cir-
cadian rhythms, body temperature is the one most closely linked to sleep and
wakefulness. The periodicity, amplitude, and length of these circadian rhythms
change with aging. For example, healthy older adults display an advanced
phase and reduced amplitude in body temperature rhythm relative to younger
adults (Czeisler et al., 1992), resulting in an earlier bedtime in the. evening and
earlier arising time in the morning. Important timing cues regulating circadian
rhythms in humans are daylight exposure, work schedules, meal times, and so-
cial interactions. With diminished activity levels and daily routines, many el-
derly have lost these important cues. Other behavioral factors, such as napping
or resting in bed, may further de synchronize the natural circadian rhythms and
interfere with nighttime sleep (Regenstein, 1980).
Behavioral and Lifestyle Factors
Behavioral and cognitive factors are also involved in late-life sleep distur-
bances, perhaps to a greater extent than at earlier ages. Aging and retirement are
often associated with reduced activity level, decreased social rhythms, and in-
creased daytime napping and time spent awake in bed. For instance, the
amount of time spent awake in bed increases with aging, even among good
sleepers. Older adults with sleep disturbances spend even more time awake in
bed, in an attempt to compensate for poor nocturnal sleep. This pattern is fur-
ther compounded by decreased physical activity associated with functional im-
pairment, failure to readjust daily routines with retirement, and boredom or
depression, in which the bed and bedroom may represent an escape for the
older person. All these factors, and their interactions with circadian rhythms,
may exacerbate an already fragmented sleep pattern in the elderly person. Dys-
functional sleep cognitions (e.g., unrealistic expectations) can also contribute to
insomnia or transform otherwise normal age-related changes in sleep patterns
into a clinical problem. These factors are discussed in the treatment section of
this chapter.
ASSESSMENT
Because of the multifactorial etiology of sleep disturbances in late life, a

comprehensive evaluation is required to make an accurate differential diagno-
sis. The following assessment procedures are recommended: a sleep history,
psychological and physical examinations, sleep monitoring and, for some dis-
orders, laboratory procedures.
Clinical History
A detailed sleep history is the most important diagnostic tool in the evalu-
ation of sleep disorders. It should elicit the type of complaint, duration,
chronology, and course; exacerbating and alleviating factors; and responses to
previous treatments. It is important to inquire about life events, psychological
and medical disorders, medication, and substance use to help establish a dif-
ferential diagnosis. Two interviews are available to gather this information in a
structured format: The Structured Interview for Sleep Disorders (Schramm et
a1., 1993), designed according to Diagnostic and Statistical Manual of Mental
Disorders, 3rd ed., rev. (DSM-III-R; American Psychiatric Association, 1987) cri-
teria, is helpful to establish a diagnosis among the different sleep disorders, and
the Structured Interview for Insomnia (Morin, 1993), is more specifically geared
for patients with a suspected diagnosis of primary or secondary insomnia.
Determining the nature of the complaint is the first step for establishing a
differential diagnosis. Difficulties falling asleep may suggest sleep-anticipatory
or performance anxiety, pain, or restless legs syndrome, whereas difficulties
maintaining sleep could be caused by nocturia, sleep apnea, periodic limb
movements, or a variety of medical factors. At times, a sleep complaint paired
with denial of affective symptoms may suggest a "masked depression." There
may be less of a social stigma attached to sleep complaints than to depression
or anxiety and some elderly persons will minimize psychological symptoma-
tology and exclusively emphasize sleeplessness. Conversely, a subjective com-
plaint of early morning awakening is not necessarily pathological or indicative
of depression, as there is a phase advance in the circadian rhythms of older peo-
ple, resulting in a natural tendency to feel sleepy earlier in the evening and to
wake up earlier in the morning.
The duration and course of insomnia (acute, intermittent, chronic) can also
have important implications for diagnosis and treatment planning. Transient in-
somnia may require an intervention that focuses directly on the precipitating con-
ditions, whereas chronic insomnia will almost always require a treatment that
also targets perpetuating factors (e.g., maladaptive sleep habits, dysfunctional
cognitions). In light of the high comorbidity between sleep and psychiatric disor-
ders, the history should identify relative onset and course of each condition in or-
der to establish whether the sleep disorder is primary or secondary in nature.
A careful functional analysis of exacerbating and alleviating factors also
can be quite useful for treatment planning. A detailed analysis of the following
factors is crucial: activities leading up to bedtime; patient's cognitions at bed-
time or in the middle ofthe night; sleep incompatible behaviors; perceived im-
pact of sleep disruptions on mood, performance, and relationships; coping
strategies; and secondary gains. Assessing the impact of disturbed sleep on
mood and daytime functioning is important to determine the clinical signifi-
cance of insomnia; inadequate or reduced sleep in the absence of residual ef-
fects or distress may not necessarily be pathological.
A medical evaluation is essential in clarifying the role of such factors as

pain, anemia, thyroid functions, cardiovascular and respiratory problems. A de-
tailed history of drugs, prescribed and over-the-counter, as well as alcohol use
is necessary. Other important areas are the dietary (e.g., caffeine), smoking, and
exercise habits and factors associated with the bedroom environment including
room temperature, mattress comfort, sleep partners, and excessive noise and
light. A review of the most common symptoms of other sleep disorders is es-
sential to differentiate between primary insomnia and insomnia secondary to
other sleep disorders. This should include a systematic review of symptoms of
sleep apnea (e.g., loud snoring, pauses in breathing), restless legs and periodic
limb movements (e.g., repetitive leg twitches during sleep), gastroesophageal re-
flux (e.g., heartburn), and parasomnias (e.g., sleep walking, violent behaviors).
Interviewing the bed partner can yield most valuable diagnostic information as
many patients may be unaware of their own snoring or breathing pauses in their
sleep, and they may deny or underestimate their degree of daytime sleepiness.
Daily Self.Monitoring
Daily sleep diary monitoring is extremely useful for establishing a diagno-

sis of some sleep disorders, and especially for insomnia. A typical sleep diary
includes entries for bedtime, arising time, sleep latency, number and duration
of awakenings, sleep duration, naps, use of sleep aids, and various indices of
sleep quality and daytime functioning (Morin, 1993). These data provide infor-
mation about a patient's sleep habits and schedules, the type of sleep problem,
and its frequency and intensity, all of which may vary considerably from the pa-
tient's global and retrospective report during a clinical interview. Despite some
discrepancies between subjective and objective measurements of sleep parame-
ters, daily morning estimates of specific sleep parameters represent a useful
index of insomnia (Coates et aI., 1982). The sleep diary is a practical and eco-
nomical assessment tool for tracking sleep patterns over long periods of time
in the home environment. It is also helpful in establishing a baseline prior to
treatment and in monitoring progress as the intervention unfolds. Due to ex-
tensive night-to-night variability in sleep patterns of insomniacs, baseline mon-
itoring should last at least lor 2 weeks (Lacks & Morin, 1992).
Psychological Assessment
Psychological assessment should be an integral component in the evalua-

tion of sleep disturbances. At the very least, a screening assessment is indicated
because of the high rate of comorbidity between sleep and psychiatric disorders
and, even when formal criteria for specific psychiatric disorders are not met,
clinical features of anxiety or depression or both are extremely common among
patients with sleep complaints. A cost-effective approach consists of using brief
screening instruments that target specific psychological features (e.g., emo-
tional distress, anxiety, depression) most commonly associated with sleep
disturbance. Instruments such as the Brief Symptom Inventory, the Beck De-
pression Inventory, and the State-Trait Anxiety Inventory can yield valuable
screening data. As for all self-report measures, these instruments are subject to
bias resulting from denial or exaggeration of symptoms and should never be
used in isolation to confirm a diagnosis. Psychometric screening should always
be complemented by a more in-depth clinical interview.
Additional self-report measures tapping various dimensions of insomnia
can also yield useful information. Some instruments are designed as a global
measure of quality (Pittsburgh Sleep Quality Index; Buysse, Reynolds, Monk,
Berman, & Kupfer, 1989), satisfaction (Coyle & Watts, 1991), or impairment of
sleep (Morin, 1993). Other scales are helpful in evaluating mediating factors of
insomnia, such as state (Pre-Sleep Arousal Scale; Nicassio, Mendlowitz, Fussel,
& Petras, 1985) and trait arousal (Arousal Predisposition Scale; Coren, 1988),
dysfunctional sleep cognitions (Beliefs and Attitudes About Sleep Scale; Morin,
1994), sleep-incompatible activities (Sleep-Behavior Self-Rating Scale; Kazar-
ian, Howe, & Csapo, 1979, and sleep hygiene (Sleep Hygiene Awareness and
Practice Scale; Lacks & Rotert, 1986). These measures are particularly useful for
designing individually tailored insomnia interventions.
Behavioral Assessment Devices
Of several behavioral assessment devices available for estimating sleep-

wake parameters, wrist actigraphy is increasingly being used in sleep research.
This activity-based monitoring system uses a microprocessor to record and
store wrist activity along with actual clock time. Data are processed through mi-
crocomputer software and an algorithm is used to estimate sleep and wake time
based on wrist activity. Despite some limitations in assessing specific sleep pa-
rameters (e.g., sleep latency), wrist actigraphy is a useful tool for estimating
sleep and wakefulness on a continuous basis throughout a 24-hour period.
Sleep Laboratory Evaluation
Nocturnal polysomnography (PSG) involves monitoring of the electroen-

cephalogram (EEG), electro-oculogram (EOG), and electromyogram (EMG).
These three parameters are sufficient to distinguish sleep from wake and to
quantify the proportion of time spent in various stages of sleep. Several addi-
tional variables (respiration, EKG, oxygen saturation, and leg movements) are
usually monitored to detect other sleep-related abnormalities (breathing pauses,
leg twitches), not recognized by the sleeping person. Nocturnal PSG is essential
for the diagnosis of sleep apnea, narcolepsy, and periodic limb movements. It
can yield useful data to document the severity of insomnia, especially in light
of the discrepancies between subjective complaints and objective findings.
However, its clinical utility in the assessment and differential diagnosis of in-
somnia is more controversial.
When daytime alertness is compromised by a sleep disorder, a Multiple
Sleep Latency Test (MSLT) is also recommended. The MSLT is a daytime assess-
ment procedure in which a person is offered five 20-min nap opportunities at
2-hour intervals throughout the day. Latency to sleep onset provides an objective
measure of physiological sleepiness. Individuals who are well rested and with-
out sleep disorders take 10 min or more to fall asleep or do not fall asleep at all.
A mean sle~p latency of less than 5 min is considered pathological and is asso-
ciated with increased risks of falling asleep at inappropriate times or places,
such as while driving. The MSLT is performed almost exclusively on patients
with a presenting complaint of excessive daytime sleepiness. Although insom-
nia patients may complain about daytime tiredness, typically they do not dis-
play pathological sleepiness on the MSLT.
Nocturnal PSG and daytime MSLT provides the most comprehensive as-
sessment of a sleep disorder. These procedures are recognized as the "gold stan-
dards" in assessing sleep and its disorders, and are clinically indicated when
the presenting complaint is excessive daytime sleepiness and when symptoms
suggestive of breathing-related disorders and periodic limb movements are
present. Although the cost-effectiveness of these procedures with insomnia
patients is equivocal, in older adults with insomnia complaints a sleep study
may still be particularly useful because this segment of the population is at in-
creased risk for several other sleep pathologies (Edinger et aJ., 1989). Coleman
and colleagues (1982) reported that 37% of patients 60 years of age or older first
diagnosed with a disorder of initiating and maintaining sleep were given a final
diagnosis of periodic movements in sleep (27%) or sleep apnea syndrome
(10%). Polysomnography is especially warranted to rule out any of these med-
ical conditions.
TREATMENT
Much of the empirical evidence on the treatment of late-life sleep distur-

bances has been gathered in the past 10 years and focused predominantly on in-
somnia. In this section, we provide a brief description of treatment methods,
summarize their efficacy, and discuss their clinical application with elderly pa-
tients. Table 13-1 outlines the main parameters of 15 outcome studies of non-
pharmacological interventions for late-life insomnia.
Late-Life Insomnia
Education
Many individuals inadvertently engage in activities that are detrimental to
sleep or refrain from simple activities that might improve sleep. Surveys indi-
cate that poor sleepers are generally better informed about sleep hygiene; how-
ever, they also engage in more unhealthy practices than good sleepers (Lacks &
Rotert, 1986). Educational interventions involve didactic teaching about
lifestyles (e.g., diet, exercise) and environmental conditions (e.g., light, noise,
temperature) that influence sleep. Education may also include information
about normal age-related changes in sleep patterns, although this component
is usually covered in cognitive therapy. A summary of sleep hygiene guidelines
is provided in the following material and more extensive discussions of these

recommendations are available elsewhere (Hauri. 1991; Morin. 1993).
Caffeine and nicotine are both stimulants that may interfere with sleep. Caf-
feine is contained in many products including coffee. tea. chocolate. and several
over-the-counter preparations. Alcohol is a CNS depressant and. although it may
facilitate sleep onset. it produces lighter and more fragmented sleep. Thus. all
caffeine products and alcohol should be discontinued 4 to 6 hours prior to bed-
time. There is little empirical evidence that any specific diet is helpful for sleep;
however. liquid intake should be restricted in the evening to minimize sleep in-
terruptions caused by nocturia, a problem that is more common among older
adults. Exercising too close to bedtime should be avoided, but regular aerobic ex-
ercise scheduled in late afternoon or early evening may deepen and consolidate
sleep. Because of the age-related reductions of deep sleep (stages 3 and 4) in
older adults. aerobic exercise is a particularly appealing intervention awaiting
controlled clinical trials. Excessive noise, light. and temperature should be min-
imized during the sleep period. The awakening threshold decreases with aging.
and the noise factor can be especially problematic for institutionalized or hospi-
talized persons. The impact of environmental factors can be minimized by im-
plementing simple changes such as wearing ear plugs. using window blinds. and
using an electric blanket or air conditioner.
Treatment studies of late-life insomnia often integrate sleep hygiene educa-
tion into multifaceted interventions (Edinger. Hoelscher, Marsh, Lipper. & In-
onescu-Pioggia, 1992; Morin. Kowatch. Barry. & Walton. 1993). However. studies
with both younger (Morin. Culbert. & Schwartz. 1994; Schoicket. Bertelson &
Lacks. 1988) and older adults (Engle-Friedman. Bootzin. Hazlewood. & Tsao.
1992) indicate that sleep hygiene alone is unlikely to be effective for chronic and
severe insomnia. Poor sleep hygiene may exacerbate insomnia but. in itself, it is
rarely the primary cause of insomnia (Buysse & Reynolds. 1990). Nonetheless.
sleep hygiene education provides a very sensible place to begin treatment to
safeguard against interference from these factors. and clinicians would be negli-
gent to ignore their potential influence (Lichstein & Riedel, 1994).
Stimulus Control
Stimulus control therapy (Bootzin. Epstein. & Wood. 1991) is designed to
curtail sleep-incompatible behaviors and to regulate sleep-wake schedules. In-
somnia is viewed as the result of maladaptive conditioning between temporal
(e.g .. bedtime) and environmental (e.g., bed) stimuli. which have been gradually
associated with wakefulness. frustration. and arousal. Some older adults are
more likely to engage in sleep-incompatible behaviors in the bedroom due to
physical discomfort and restricted range of movement. Daytime napping is also
common practice and. although it may not interfere with nighttime sleep in the
elderly to the same extent as it does in young adults (Aber & Webb. 1986;
Feinberg et a1 .• 1985), multiple and long naps taken late in the day are likely to
result in nighttime sleep that is light. restless, and subject to multiple awaken-
ings.
Stimulus control therapy consists of the following instructions: (a) going to
bed only when sleepy; (b) leaving the bed for another room when unable to fall
Table 13-1. Insomnia Treatment in Older Persons
Treatment Sex Age Dependent

Format of duration N (per ('Yo of (group sleep Sleep
Authors (year) treatment (weeks/hours) condition) female) mean) Diagnosis variables medication
Alperson & Biglan (1979) self-administered 4 N=29 48.0 55+ sleep-onset SOL, TST yes
(RT, SC, MC)
Anderson et a1. (1988) individual 6/2.5 SRT=8 70.0 63.8 mixed TST, WASO, no
SC=8 SE, SOL
WL=4
Campbell, Dawson, & individual 1.4/20 BLE=8 56.3 70.4 advanced TST, SOL, no
Anderson (1993) MC=8 sleep phase SE, WASO
syndrome
Davies, Lacks, Storandt, & group 4/4 CC=22 47.1 58.6 maintenance WASO no
Bertelson (1986) WL=12
Edinger, Hoelscher, Marsh, individual 4/4 CBT& 75.0 61.9 maintenance SOL, WASO, no
Lipper, & Ionescu-Pioggia RT= 7 TST, SE
(1992)
Engle-Friedman, Bootzin, individual 4/4 N=53 66.3 59.6 mixed SOL, WASO no
Hazelwood, & Tsao (1992) (SH, RT, SC, MC)
Friedman, Bliwise, Yesavage, individual 4/4 RT=12 63.6 69.2 mixed TST, SE, yes
& Salom (1991) SRT= 10 SOL, WASO
Hoelsher & Edinger (1988) individual 4/4 MCT=4 100.0 65.3 maintenance WASO, SOL, no
TST, SE
Lichstein & Johnson (1993) individual 2/3 MI= 19 100.0 66.2 mixed SOL, WASO, yes
NMI = 18 TST,SE
NI=20
Morin & Azrin (1987) group 4/4 SC= 7 66.7 57.0 maintenance WASO no
IT= 7
WL=7
Morin & Azrin (1988) group 4/6 SC=9 63.0 67.4 mixed SOL. TST. yes
IT = 8 WASO
WL= 10
Morin. Colecchi, Stone. group/ 8/8 CBT= 18 64.1 64.5 mixed WASO.SOL. yes
Sood. & Brink (1995) individual PCT = 20 SE. TST.
CBT+ PCT= 20 EMA. TWT.
PLA = 20 NA
Morin. Kowatch. Barry. & group 8/12 CBT= 12 70.8 67.1 mixed SOL. WASO. no
Walton (1993) WL=12 TST. SE
Puder. Lacks. Bertelson. & group 4/4 SC=9 81.3 67.1 sleep-onset SOL no
Storandt (1983) WL=7
Riedel, Lichstein. & group v = 30 min.l2 V + G NI = 25 65.6 67.4 mixed SOL. WASO. no
Dwyer (1995) V +G= 2/4 V +G=25 TST.SE
V NI = 25
V=25
WL=25
Note: SOL = Sleep Onset Latency. WASO =Wake After Sleep Onset. EMA =Early Morning Awakening. TWT =Total Wake Time. SE = Sleep Efficiency. TST =Total Sleep Time. NA
= Number of Awakenings. SC =Stimulus Control. IT = Imagery Training. WL = Waiting List. RT = Relaxation Therapy. CBT =Cognitive Behavior Therapy. NI = Noninsomniacs. SH
= Sleep Hygiene. MC = Measurement Control Group. CC =Countercontrol Treatment. BLE =Bright Light Exposure. SRT = Sleep Restriction Therapy. MCT = Multicomponent Treat-
ment. PLA = Placebo. PCT =Pharmacotherapy. MI = Medicated Insomniacs. NMI =Nonmedicated Insomniacs. V =Video. G = Therapist Guidance.
asleep or return to sleep within 15 to 20 minutes, and returning to bed only

when sleep is imminent; (c) repeating the previous instruction as often as nec-
essary throughout the night; (d) arising at the same time every morning regard-
less of the amount of sleep obtained; (e) curtailing sleep-incompatible activities
(e.g., reading, watching TV in the bedroom); the bed and bedroom are reserved
for sleep and sexual activities; and (0 minimizing daytime napping. The main
therapeutic goals are to strengthen the association between sleep and the con-
ditions under which it typically occurs, and to consolidate a stronger sleep-
wake rhythm.
Controlled studies with older adults indicate that stimulus control therapy,
singly or combined with other interventions, is effective for both sleep-onset
(Engle-Friedman et al., 1992; Puder, Lacks, Bertelson, & Storandt, 1983) and
sleep maintenance problems (Edinger et al., 1992; Hoelscher & Edinger, 1988;
Morin & Azrin, 1988; Morin, Kowatch, et al., 1993). Improvement rates are com-
parable with those obtained with younger people (Lacks & Morin, 1992; Morin
et al., 1994), and therapeutic benefits are well maintained at long-term follow-
ups. Substantial reduction of hypnotic usage has also been noted among med-
icated elderly patients (Morin & Azrin, 1988; Morin, Kowatch, et al., 1993).
Although stimulus control therapy is a generally well accepted and credi-
ble treatment, adherence to these procedures is variable across individuals and
for the different instructions. Some procedures (e.g., getting out of bed when
unable to sleep) may be unpleasant, especially when they have to be imple-
mented in the middle of the night. Countercontrol is a variation of the standard
stimulus control instruction in that patients do not have to leave the bed.
Rather, they are asked to stay in bed and engage in some worry-incompatible
activity (e.g., reading) when unable to sleep. This technique has produced
comparable results to the standard stimulus control instructions in one study
(Davies, Lacks, Storand, & Bertelson. 1986). For older adults who are reluctant
to comply with the standard stimulus control instructions. this can be a more
acceptable alternative. although it is contrary to the basic principles of stimu-
lus control procedures. Nonetheless. treatment adherence is a critical issue
and the clinician must remain flexible to optimize outcome and prevent
dropout or failures.
Sleep Restriction
Sleep restriction consists of curtailing the amount of time spent in bed to
the actual sleep time (Spielman, Saskin, & Thorpy, 1987). The rationale behind
this treatment is that insomniacs, especially older adults, spend excessive
amounts of time in bed in a misguided effort to rest or sleep longer. However,
excessive time spent in bed produces more fragmented sleep and may very well
contribute to perpetuating insomnia. Restricting time in bed creates a mild
sleep deprivation, which itself produces more consolidated and deeper sleep.
Sleep-wake schedules are individualized according to estimated total subjec-
tive sleep time from a daily diary kept for 2 weeks. The amount oftime allowed
in bed is initially restricted to this average. For example, if a patient reports
sleeping 6 hours per night but spends 8 hours in bed. the time allowed in bed
(i.e., sleep window) would be 6 hours. Bedtimes and arising times are set at
fixed hours. Weekly adjustments in the sleep window are made contingent on
sleep efficiency (ratio of sleep time to time in bed multiplied by 100). Time in
bed is increased by about 20 minutes when sleep efficiency exceeds 90%, de-
creased by the same amount when sleep efficiency is lower than 80%, and kept
constant when sleep efficiency is between 80% and 90%. With the elderly,
Glovinsky and Spielman (1991) recommend lowering the sleep efficiency crite-
ria by 5%. These adjustments are made periodically, usually on a weekly basis,
until an optimal sleep duration is reached. Time in bed should not be set be-
low 4 to 5 hours per night, as it might cause excessive daytime sleepiness. A
brief midday nap can counteract this effect without being detrimental to treat-
ment. Daytime napping may be permissible early in treatment as long as it does
not exceed 1 hour and is scheduled before midafternoon.
Sleep restriction is a relatively novel approach to treat insomnia; however,
early studies suggest that it may be the best currently available intervention for
late-life insomnia (Lichstein & Riedel, 1994). Only two studies have evaluated
its efficacy when used alone with older adults (Anderson et 01., 1988; Fried-
man, Bliwise, Yesavage, & Salom, 1991), but several more have combined sleep
restriction with stimulus control and cognitive restructuring procedures
(Edinger et aI., 1992; Hoelscher & Edinger, 1988; Morin, Kowatch, et aI., 1993;
Morin, Colecchi, Ling, & Sood, 1995). The main effect of sleep restriction is to
improve sleep efficiency, which is reflected by a shorter time to fall asleep and
by less frequent and shorter nocturnal awakenings. Although sleep duration is
increased by a modest 30 to 60 minutes, patients are generally more satisfied
with the quality of their sleep patterns. Therapeutic gains are also well main-
tained over time. Sleep restriction is a potentially useful treatment for the man-
agement of insomnia among elderly patients in institutions, an environment
where excessive amounts of time spent in bed may be an important exacerbat-
ing factor of sleep disturbances.
Relaxation
Relaxation interventions are based on the premise that excessive arousal
interferes with sleep. These methods seek to reduce somatic (e.g., progressive
muscle relaxation, autogenic training) or cognitive arousal (e.g., imagery train-
ing, meditation). Relaxation-based interventions are the most widely used and
studied nonpharmacological treatments for insomnia (Lichstein & Fisher, 1985).
Although relaxation is helpful with younger adults, there is significantly more
variability in outcome with advancing age (Edinger et 01.,1992; Friedman et 01.,
1991). In a study comparing the efficacy of sleep restriction and relaxation in
older adults, Friedman and colleagues (1991) reported significant benefits for
both methods. However, improvement rate at the 3-month follow-up was twice
as high in the sleep restriction condition compared with the relaxation group.
Edinger and colleagues (1992) treated older adults sequentially with sleep re-
striction and relaxation and found that relaxation added little to the treatment
effect of sleep restriction. When used alone, relaxation procedures may not be
potent enough for chronic insomnia, especially in the elderly. Lichstein and
Johnson (1993) obtained good results but only for nonmedicated insomniacs.
They suggested that relaxation may be too physically demanding and complex
290 Charles M. Morin et 01.
with some older adults. Difficulties concentrating and sustaining attention for
prolonged periods of time, as well as lower credibility for these procedures
have also been reported (Morin & Azrin, 1988).
Cognitive Therapy
Older adults with chronic insomnia endorse more frequent and stronger
dysfunctional beliefs and attitudes about sleep than self-defined good sleepers
(Morin, Stone, Trinkle, Mercer, & Remsberg, 1993). Some entertain more unre-
alistic expectations regarding their sleep needs, whereas others believe that in-
somnia is an inevitable fact of aging. Still others are concerned about the fact
that insomnia may have serious consequences for their physical health. Older
persons are often unaware that age-related decreased nocturnal sleep time and
quality do not necessarily produce daytime dysfunctions; consequently, they
may struggle to maintain sleep patterns that are unrealistic for their age groups.
For example, the belief that 8 hours of sleep is essential to maintain adequate
daytime functioning is very common. If, because oflack of knowledge, seniors'
sleep goals are not adjusted to conform with age-correlated sleep changes, the
pursuit of superfluous sleep could ensue, a condition that Lichstein has labeled
"insomnoid state" (Riedel, Lickstein, & Dwyer, 1995). Also, exclusive attribu-
tion of daytime fatigue, impaired performance, and mood disturbances to poor
sleep is counterproductive and is likely to create performance anxiety. Faulty
beliefs about sleep-promoting practices can also perpetuate sleep difficulties.
For example, insomniacs often believe that the best way to get some sleep is to
stay in bed and try harder, or that the best coping strategy to minimize the con-
sequences of sleep loss is to take daytime naps.
Cognitive therapy seeks to alter dysfunctional beliefs and attitudes that are
instrumental in exacerbating the vicious circle of insomnia, emotional arousal,
fear of sleeplessness, and more sleep disturbances. Therapy relies on cognitive
restructuring procedures similar to those used in the management of anxiety
and affective disorders (e.g., reappraisal, reattribution, and decatastrophizing).
Training and guidance is provided to identify dysfunctional sleep cognitions,
challenge their validity, and replace them with more adaptive substitutes. The
main issue is not to deny the presence of sleep difficulties or their impact on
daytime functioning but to view insomnia from a more realistic perspective.
Specific targets for intervention include (a) unrealistic sleep expectations, (b)
misconceptions about the causes of insomnia, (c) misattributions or amplifi-
cations of its consequences, (d) performance anxiety resulting from excessive
attempts at controlling the process of sleep, and (e) learned helplessness asso-
ciated with the perceived unpredictability of sleep. The Dysfunctional Beliefs
and Attitudes About Sleep Scale (Morin, 1993) is useful in identifying dys-
functional sleep cognitions and in selecting relevant targets for cognitive ther-
apy. A more extensive discussion of cognitive therapy for insomnia is available
elsewhere (Morin, 1993).
Cognitive therapy has been evaluated as a part of multicomponent treat-
ment protocols with older adults (Edinger et a1., 1992; Morin, Kowatch, et a1.,
1993; Morin, Colecchi, Ling, & Sood, 1995), but its efficacy as a single treatment
modality has not yet been documented. Clinical evidence, however, suggests
that cognitive therapy is a most important therapeutic component in the clini-

cal management of insomnia and, perhaps, even more so in late life. It is par-
ticularly helpful in distinguishing pathological from normal changes in sleep
patterns, which is useful in setting some realistic therapeutic goals, alleviating
performance anxiety, and reinstating a sense of control over sleep. Cognitive
therapy is also helpful in decatastrophizing the impact of insomnia and in
preparing patients to cope more adaptively with some residual sleep difficulties
that should be expected even after treatment completion.
Pharmacotherapy
Pharmacotherapy is the most frequently used method for treating sleep dis-
turbances, and even more so among elderly patients. Several classes of drugs
are used in the pharmacological management of insomnia: benzodiazepines
(e.g., flurazepam, temazepam, triazolam) and related GABA-receptor agents
(e.g., zolpidem and zopiclone), sedating antidepressants (e.g., amitriptyline,
doxepin), antihistamines, and older drugs such as chloral hydrate and mepro-
bamate. Neuroleptics are also used for the management of sleep disturbances
associated with psychosis, dementia, and organic brain syndromes.
Benzodiazepine-receptor agents, the most commonly prescribed drugs for
insomnia, are effective with short-term usage to reduce sleep latency and time
awake after sleep onset, increase total sleep time, and improve sleep efficiency.
However, most of these agents suppress slow-wave (stages 3 and 4) sleep, which
is considered the most restorative sleep. Thus, although sleep continuity and
duration are improved, sleep quality is usually worsened. All sedative-hyp-
notic drugs lead to tolerance and become ineffective with long-term usage. In
addition, these drugs are especially hazardous to older people because of re-
duced metabolic functioning with aging and increased risk of interactions with
other medications. Long-acting agents have residual effects that can impair cog-
nitive functions, increase the risk of falls and hip fractures, and exacerbate the
already higher incidence of sleep-related respiratory impairment. Other draw-
backs include rebound anxiety and insomnia, withdrawal symptoms, drug and
alcohol interactions, and the potential for dependency, which is often more
psychological than physical in nature (Morin & Wooten, 1996). Although hyp-
notic medications can be useful in the short-term management of insomnia,
these agents are not recommended for prolonged usage (NIH, 1991).
Combined Cognitive-Behavior Therapy and Pharmacotherapy

Only one study has been conducted to evaluate the efficacy of cognitive-
behavior therapy and pharmacotherapy (temazepam), alone and in combination,
for late-life insomnia (Morin, Colecchi, Stone, Sood, & Brink, 1995). The sample
consisted of 78 older adults (mean age = 65 years) with primary and chronic in-
somnia, suffering predominantly from sleep-maintenance or mixed onset and
maintenance difficulties. The findings showed that all three active treatments
were more effective than drug-placebo at mid (4 weeks) and late treatment (8
weeks) on the two main outcome measures of time awake after sleep onset and
sleep efficiency. Although there was a slight trend for the combined approach to
yield better outcome, no statistically significant differences emerged among the

active treatment conditions at posttreatment. These results were documented
with both self-report data from daily sleep diaries and EEG-defined sleep mea-
sures from nocturnal polysomnography. Follow-up data obtained at 3, 12, and 24
months after treatment showed that subjects treated with cognitive-behavior
therapy sustained their clinical gains, whereas those treated with drug therapy
alone did not. Long-term effects of the combined intervention showed a signifi-
cant loss of therapeutic benefits from posttreatment to follow-ups, although
there was much variability across subjects in the combined condition and over
the three follow-up periods.
Drug-Dependent Insomnia
Drug-dependent insomnia is recognized as a treatment-refractory health

problem. Although controlled studies of psychological interventions for late-life
insomnia have yielded promising results with unmedicated patients, only two
studies have examined the efficacy of those treatment methods specifically for
hypnotically medicated older adults. Lichstein and Johnson (1993) provided el-
derly community-dwelling women (hypnotically medicated insomniacs, non-
hypnotically medicated insomniacs, and noninsomniacs) with three relaxation
training sessions over a 2-week period. Medicated subjects reduced their med-
ication by 47% from baseline to a 6-week follow-up without sleep deterioration.
Modest improvements in sleep efficiency were obtained from baseline to post-
treatment for either the medicated (62% to 70%) or drug-free (64% to 72%)
insomniacs. In a pilot study (Morin, Colecchi, Ling, & Sood, 1995), five hyp-
notic-dependent insomnia patients were treated with cognitive-behavior therapy
combined with a supervised medication tapering schedule. Four participants
discontinued medication within 6 to 8 weeks and the fifth decreased drug intake
by 90% over baseline. Sleep patterns initially deteriorated during the with-
drawal period but tended to return toward normal values at follow-up. These
findings, although very preliminary, suggest that psychological procedures,
alone or combined with a supervised medication taper schedule, may facilitate
reduction of hypnotic medications in older adults with insomnia. Additional re-
search is needed to document long-term maintenance of therapeutic gains.
Management of Sleep Disturbances in Dementia
The management of sleep disturbances in dementia can be a challenging

task for caregivers and clinicians alike. As for all other patients, sleep distur-
bances in demented patients can be caused or exacerbated by primary sleep
disorders (e.g., sleep apnea) and by many other medical conditions (e.g., sys-
temic diseases, drug toxicity, electrolyte imbalances). Thus, a careful diagnos-
tic workup is necessary before initiating treatment.
Sedative-hypnotic drugs are prescribed three times more frequently among
institutionalized than among community-dwelling elderly persons (Mor-
gan, 1987). As for otherwise healthy insomniacs, short-term usage of sedative-
hypnotics can be useful for acute sleep disturbances. However, these agents
have minimal effects on nocturnal agitation accompanying dementia and, in
some cases, may actually worsen the condition. Also, their long-term use often
results in habituation, loss of efficacy, and drug-dependency. Adverse daytime
effects on cognitive and psychomotor functioning can be more serious in the al-
ready more frail demented patients than in healthy individuals. Small doses of
neuroleptic such as haloperidol and thioridazine are often used, but these po-
tent drugs have important side effects and are always associated with risks of
tardive dyskinesia.
With adequate family and nursing staff support, behavioral and environ-
mental interventions can be of considerable help in minimizing nocturnal sleep
and behavioral disturbances. The most important step is to maximize wakeful-
ness during the daytime hours. Demented patients spend a good part of their
days dozing and, given the inverse relationship between daytime wakefulness
and nocturnal sleep (D. 1. Bliwise, Bevier, Bliwise, Edgar, & Dement, 1990), it is
essential for caregivers and nursing staff to keep patients awake during the day.
This can be accomplished by scheduling a variety of social activities, restricting
time spent in bed, and even by physical or manual stimulation. It is also im-
portant to incorporate light physical activity into the patient's daily routines. It
may also be important for nursing home administrators to implement policies
to enforce a regular arising time and to limit the amount of time patients are
kept in bed, at least for those who are not bedridden. It is equally important to
educate caregivers and nursing staff about the nature and extent of sleep dis-
turbances to expect in demented patients. Even when daytime functioning may
still be relatively adequate, it is certainly unrealistic to expect these patients to
sleep uninterruptedly from 9:00 P.M. to 7:00 A.M.
The light-dark cycle is an important factor regulating the sleep-wake cycle
in humans. Regular exposure to outdoor light is particularly important to older
adults, as their circadian rhythms tend to become more disorganized. Several
preliminary reports suggest that bright light exposure (i.e., phototherapy) may
strengthen the circadian periodicity ofthe sleep-wake cycle and improve night-
time sleep in demented, as well as nondemented, elderly patients (Campbell,
Dawson, & Anderson, 1993; Campbell, Kripke, Gillin, & Hrubovcak, 1988;
Campbell, Satlin, Volicer, Ross, & Herz, 1991). Adequate intensity and duration
of exposure to bright light are important factors in obtaining the desired effects.
Light intensity should be above 2,000 lux (which is equivalent to outdoor ex-
posure on at least a partially sunny day) for at least 2 to 3 hours. Simply leaving
a patient near a window is unlikely to have any beneficial effect. Bright light
therapy may also be helpful in alleviating some of the sleep disruptions and ag-
itation in the sundown syndrome.
Nursing home patients are particularly at risk for environmentally induced
sleep disturbances. Minimizing excessive noise and light and providing a com-
fortable mattress and adequate room temperature are essential. Routine medical
procedures (e.g., vital signs) and drug administration should be scheduled, as
much as possible, when the patient is already awake. Several environmental
manipulations may also be helpful in minimizing disruptions and risk of in-
juries associated with nocturnal wandering. At home, it is important to have pa-
tients sleep on the first floor, to remove objects that may be dangerous, and even
to install an alarm system to wake the caregiver if the patient attempts to leave
the room. The use of nocturnal caregivers, modeled after the British "night-
watchers" system, can provide some respite to family members and, in the
institutional environment, nursing staff or occupational therapists might sched-
ule supervised activities in the early morning hours to minimize disruptions for
other patients.
IMPLICATIONS FOR CLINICAL PRACTICE

AND FUTURE RESEARCH
Increased incidence of health problems, medication use, and stressful life

events associated with aging may predispose older people to more frequent and
more severe sleep disruptions. Sleep disturbances in later life are associated
with significant medical and psychiatric comorbidity and can produce distress
in the affected individuals, their families, and caregivers. In spite of their high
incidence and debilitating effects, sleep disturbances are often unrecognized by
health care professionals and, when treatment is initiated, it is too often limited
to pharmacotherapy. This is unfortunate because significant advances have
been made in the nonpharmacological management of sleep disturbances in the
past few years and a wide variety of interventions have been successfully em-
ployed to treat this common problem in late life.
Behavioral, cognitive, and educational methods have produced substantial
improvements on a number of sleep continuity parameters and have reduced
emotional distress often associated with sleep disruptions. Sleep duration per
se is only modestly improved, but treated patients are generally more satisfied
with the quality of their sleep. Treatment effects have been documented with
both subjective (daily sleep diaries) and objective measurements (polysomnog-
raphy and mechanical devices). Although some early research suggested that
older adults had a poorer prognosis (Alperson & Biglan, 1979), more recent
findings indicate that once older patients are well screened for other sleep dis-
orders (e.g., sleep apnea, periodic movements in sleep), their response to treat-
ment is comparable with that of younger people. Sleep restriction and stimulus
control procedures are the most effective single therapy components for late-life
insomnia, with relaxation-based methods producing more variable outcomes.
Cognitive therapy is a promising intervention, but has not been adequately eval-
uated as the sole treatment modality.
In light of the multifaceted nature of late-life sleep disturbances, clinicians
do not have to (and should not) restrict their interventions to a single treatment
modality. Multicomponent approaches that are specifically tailored to the
changing needs and circumstances of the older adults should be considered to
optimize therapeutic benefits. Despite the availability of effective treatment
methods for the outpatient management of late-life insomnia, a number of bar-
riers (e.g., cost, transportation) may prevent some elderly persons from access-
ing these resources. Group treatment not only reduces the cost, but has the
distinct advantage of providing opportunities for social interactions with and
support from peers experiencing similar problems. Although direct compar-
isons of individual and group therapies are needed with the elderly, these two
treatment modalities have yielded comparable results with younger adults.

Self-help treatment provided in the forms of written brochures and audio or
video cassettes may also be a useful alternative to professionally guided treat-
ment (Alperson & Biglan, 1979; Riedel et 01., 1995). This is an area for further
study as many older adults do not have the financial resources or transporta-
tion to receive individual treatment provided by a professional therapist.
Large-scale educational interventions targeting senior citizen groups could
provide basic information about normal changes in sleep patterns with aging
and specific recommendations for maintaining healthy sleep patterns in late
life. This approach might prevent the development of clinical insomnia and
minimize reliance on hypnotic medications. This is a particularly appealing
avenue for future research as non pharmacological interventions are generally
perceived as more acceptable than pharmacotherapy (Morin, Gaulier, Barry, &
Kowatch, 1992).
Much ofthe empirical evidence available on the treatment oflate-life sleep
disturbances has been obtained from healthy, medication-free, community-liv-
ing older adults. The generalizability of the findings to medically ill, hypnotic-
dependent, and to the more frail, institutionalized elderly patients is unknown.
Although these patients may be more refractory to treatment, many of the pro-
cedures reviewed in this chapter may be of clinical benefit to those patients as
well. For example, although some data suggest that hypnotic-dependent pa-
tients are not as responsive to treatment as drug-free patients are, preliminary
findings indicate that combining cognitive-behavior therapy with a structured
medication withdrawal program can facilitate discontinuation of hypnotic
medications. Perhaps the greatest challenge for clinicians and researchers is to
develop effective nonpharmacological interventions for demented and insti-
tutionalized patients. Sleep disturbances in demented patients are exceedingly
difficult to manage. and it may be only through a judicious combination of be-
havioral, environmental, and pharmacological interventions that patients, care-
givers, and nursing staff may obtain some relief.
REFERENCES
Aber. T., R., & Webb, W. B. (1986). Effects of a limited nap on night sleep in older subjects. Psychol-
ogy and Aging, 4, 300-302.
Alperson, J., & Biglan, A. (1979). Self-administered treatment of sleep onset insomnia and the im-
portance of age. Behavior Therapy, 10,347-356.
(3rd ed., revised). Washington, DC: Author.
Ancoli-Israel, S., Kripke, D. F., Mason, W., & Messin, S. (1981). Sleep apnea and nocturnal my-
oclonus in senior population. Sleep, 4, 349-358.
Anderson, M. W., Zendeli, S. M., Rosa. D. P., Rubinstein. M. 1.. Herrera. C. 0 .. Simons, 0 .. Caruso,
1.. & Spielman. A. J. (1988). Comparison of sleep restriction therapy and stimulus control in
older insomniacs: An update. Sleep Research, 17, 141.
Benca, R. M .. Obermeyer. W. H .• Thisted. R. A .• & Gillin, J. C. (1992). Sleep and psychiatric disor-
ders: A meta analysis. Archives of General Psychiatry. 49, 651-668.
Bliwise, D. 1. (1993). Sleep in normal aging and dementia. Sleep, 16,40-81.
Bliwise D. L., Tinklenberg, J., Yesavage, J. A., Davies, H., Pursley, A. M., Petta, D. E., Widrow, L.,
Guilleminault, C., Zarcone, V. P., & Dement, W. C. (1989). REM latency in Alzheimer's disease.
Biological Psychiatry, 25, 320-328.
Bliwise, D. L., Bevier, W., Bliwise, N., Edgar, D., & Dement, W. C. (1990). Systematic 24-hr behav-
ioral observations of sleep and wakefulness in a skilled care nursing facility. Psychology and
Aging, 5, 16-24.
Bliwise, D. L., Yesavage, J., & Tinklenberg, J. (1992). Sundowning and rate of decline in mental func-
tion in Alzheimer's disease. Dementia, 3, 335-341.
Bliwise, N. G., Bliwise, D. L., & Dement, W. C. (1985). Age and psychopathology in insomnia. Clin-
ical Gerontologist, 4, 3-9.
Bootzin, R., Engle-Friedman, M. E., & Hazelwood, L. (1983). Insomnia. In P. M. Lewinsohn & L. Teri
(Eds.), Clinical geropsychology: New directions in assessment and treatment (pp. 81-115).
Elmsford, NY: Pergamon.
Bootzin, R., Epstein, D., & Wood, J. M. (1991). Stimulus control instructions. In P. J. Hauri (Ed.),
Case studies in insomnia (pp. 19-28). New York: Plenum.
Buysse, D. J., & Reynolds. C. F. (1990). Insomnia. In M. J. Thorpy (Ed.). Handbook of sleep disorders
(pp. 395--433). New York: Dekker.
Buysse. D. J., Reynolds. C. F.• Monk. T. H .• Berman. S. R., & Kupfer. D. J. (1989). The Pittsburg Sleep
Quality Index: A new instrument for psychiatric practice and research. Psychiatry Research,
28, 193-213.
Buysse. D. J.• Reynolds. C. F.• Kupfer, D. J.• Thorpy, M. J. Bixler. E., Manfredi. R., Kales. A .• Vgontzas.
A., Stepanski. E.• Roth. T.• Hauri, P.• & Mesiano. D. (1994). Clinical diagnoses in 216 patients
using the international classification of sleep disorders (ICSD). DSM-IV and ICD-10 categories:
A report from the APAlNIMH DSM-IV field trial. Sleep, 17.630-637.
Campbell, S. S., Kripke, D. F.• Gillin. J. C., & Hrubovcak. J. C. (1988). Exposure to light in healthy el-
derly subjects and Alzheimer's patients. Physiology and Behavior. 42, 141-144.
Campbell. S. S .• Satlin. A .• Volicer. L.• Ross. V.• & Herz. L. (1991). Management of behavioral and
sleep disturbance in Alzheimer's patients using timed exposure to bright light. Sleep Re-
search, 20. 446.
Campbell, S. S.• Dawson. D. & Anderson. M. W. (1993). Alleviation of sleep maintenance insomnia
with timed exposure to bright light. Journal of the American Geriatrics Society, 41, 829-836.
Coates. T. J., Killen. J. D.• George. J., Marchine. E.• Silverman. S., & Thoresen. C. (1982). Estimating
sleep parameters: A multitrait multimethod analysis. Journal of Consulting and Clinical Psy-
chology. 50, 345-352.
Coben. L. A .• Chi. D.• Snyder. A. Z.• & Storandt. M. (1990). Replication of a study of frequency analy-
sis of the resting awake EEG in mild probable Alzheimer's disease. Electroencephalography
Clinical Neurophysiology. 75. 148-154.
Coleman. R. M.• Roffwarg, H. P.• Kennedy, S. J.• GuilleminauIt, C., Cinque. J.• Cohn, M. A., Karacan.
1.. Kupfer. D. J.• Lemmi. H .• Miles, L. E.. Orr, W. C.• Phillips. E. R., Roth. T.• Sassin. J. F.•
Schmidt. H. S., Weitzman. E. D.• & Dement. W. C. (1982). Sleep-wake disorders based on a
polysomnographic diagnosis: A national cooperative study. Journal of the American Medical
Association. 247, 997-1003.
Coren. S. (1988). Prediction of insomnia from arousabillty predisposition scores: Scale development
and cross-validation. Behaviour Research and Therapy. 26, 415--420.
Coyle, K.. & Watts. F. N. (1991). The factorial structure of sleep dissatisfaction. Behaviour Research
and Therapy. 29, 513-520.
Czeisler. C. A .• Dumont. M., Duffy, J. F.• Steinberg. J. D., Richardson. G. S., Brown, E. N.• Sanchez,
R., Rios, C. D., & Ronda, J. M. (1992). Association of sleep-wake habits in older people with
changes in output circadian pacemaker. Lancet, 340, 933-936.
Davies. R.. Lacks, P., Storandt. M.• & Bertelson. A. D. (1986). Counter-control treatment of sleep-
maintenance insomnia in relation to age. Psychology and Aging, 1, 233-238.
Dement, W. C., Miles. L. E., & Carskadon, M. A. (1982). "White paper" on sleep and aging, Journal
of the American Geriatrics Society, 3D, 25-50.
Edinger. J. D., Hoelscher, T. J.• Webb. M. D.• Marsh. G. R.. Radtke. R. A .• & Erwin. C. W. (1989).
Polysomnographic assessment of DIMS: Empirical evaluation ofits diagnosis value. Sleep. 12,
315-322.
Edinger, J. D., Hoelscher, T. J., Marsh, G. R, Lipper, S., & Ionescu-Pioggia, M. (1992). A cognitive-
behavioral therapy for sleep-maintenance insomnia in older adults. Psychology and Aging, 7,
282-289.
Engle-Friedman, M., Bootzin, R R., Hazlewood, L., & Tsao, C. (1992). An evaluation of behavioral
treatments for insomnia in the older adult. Journal of Clinical Psychology, 48, 77-90.
Feinberg, I., Koresko, R 1., & Heller, N. (1967). Sleep patterns as a function of normal and patho-
logical aging in man. Journal of Psychiatric Research, 5, 107-144.
Feinberg, I., March, J. D., Floyd, T. C., Jimison, R, Bossom-Demitrach, 1., & Katz, P. H. (1985).
Homeostatic changes during postnap sleep maintain baseline levels of delta sleep EEG. Elec-
troencephalography and Clinical Neurophysiology, 61, 134-137.
Ford, D. E., & Kamerow, D. B. (1989). Epidemiologic study of sleep disturbances and psychiatric
disorders: An opportunity for prevention? Journal of the American Medical Association, 262,
1479-1484.
Friedman, 1., Bliwise, D. 1., Yesavage, J. A., & Salom, S. R (1991). A preliminary study comparing
sleep restriction and relaxation treatments for insomnia in older adults. Journal of Gerontol-
ogy, 46, Pl-8.
Gallagher-Thompson, D., Brooks, J. 0., Bliwise, D. 1., Leader, J., & Yesavage, J. A. (1992). The rela-
tions among caregiver stress, "sundowning" symptoms, and cognitive decline in Alzheimer's
disease. Journal of the American Geriatrics Society, 40, 807-810.
Gallup Organization. (1991). Sleep in America. Princeton, NJ: Author.
Glovinsky, P. B., & Spielman, A. J. (1991). Sleep restriction therapy. In P. Hauri (Ed.), Case studies
in insomnia (pp. 49-63). New York: Plenum.
Guilleminault, C. (1989). Clinical features and evaluation of obstructive sleep apnea. In M. H.
Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (pp.
552-558). Philadelphia: Saunders.
Hart, R P., Morin, C. M., & Best, A. M. (1995). Neuropsychological performance in elderly insomnia
patients. Aging and Cognition, 2(4), 268-278.
Hauri, P. J. (1991). Sleep hygiene, relaxation therapy, and cognitive interventions. In P. J. Hauri
(Ed.), Case studies in insomnia (pp. 65-84). New York: Plenum.
Hoelscher, T., & Edinger, J. E. (1988). Treatment of sleep-maintenance insomnia in older adults:
Sleep period reduction, sleep education, and modified stimulus control. Psychology and Ag-
ing, 3, 258-263.
Hohagen, E, Kappler, C., Schramm, E., Rink, K., Weyerer, S. Riemann, D., & Berger, M. (1994).
Prevalence of insomnia in elderly general practice attenders and the current treatment modal-
ities. Acta Psychiatrica Scandinavica, 90, 102-108.
Jacobs, D., Ancoli-Israel, S., Parker, L., & Kripke, D. F. (1988). Sleep and wake over 24-hours in a
nursing home population. Sleep Research, 17, 191.
Kazarian, S. S., Howe, M. G., & Csapo, K. G. (1979). Development of the sleep behavior self-rating
scale. Behavior Therapy, 10,412-417.
Kennedy, G. J., Kelman, H. R, & Thomas, C. (1991). Persistence and remission of depressive symp-
toms in late life. American Journal of Psychiatry, 148, 174-178.
Lacks, P., & Morin, C. M. (1992). Recent advances in the assessment and treatment of insomnia.
Journal of Consulting and Clinical Psychology, 60, 586-594.
Lacks, P., & Rotert, M. (1986). Knowledge and practice of sleep hygiene techniques in insomniacs
and poor sleepers. Behaviour Research and Therapy, 24, 365-368.
Lichstein, K. 1., & Fisher, S. M. (1985). Insomnia. In M. Hersen & A. S. Bellack (Eds.), Handbook of
clinical behavior therapy with adults (pp. 319-352). New York: Plenum.
Lichstein, K. L., & Johnson, R S. (1993). Relaxation for insomnia and hypnotic use in older women.
Psychology and Aging, 8, 103-111.
Lichstein, K. 1., & Riedel, B. W. (1994). Behavioral assessment and treatment of insomnia: A review
with an emphasis on clinical application. Behavior Therapy, 25, 659-688.
Mellinger, G. D., Balter, M. B., & Uhlenhuth, E. H. (1985). Insomnia and its treatment: Prevalence
and correlates. Archives of General Psychiatry, 42, 225-232.
Montplaisir, J., & Godbout, R (1989). Restless legs syndrome and periodic movements during sleep.
In M. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (pp.
402-409). Philadelphia: Saunders.
Morgan, K. (1987). Sleep and aging: A research-based guide to sleep in later life. Baltimore: Johns
Hopkins University Press.
Morgan, K., Dallosso, H., Ebrahhn, S., Arie, T., & Fentem, P. H. (1988). Characteristics of subjective
insomnia in elderly living at home. Age and Aging, 17, 1-7.
Morin, C. M. (1993). Insomnia: Psychological assessment and management. New York: Guilford.
Morin, C. M. (1994). Dysfunctional beliefs and attitudes about sleep: Preliminary scale development
and description. The Behavior Therapist. 17, 163-164.
Morin, C. M., & Azrin, N. H. (1988). Behavioral and cognitive treatments of geriatric insomnia. Jour-
nal of Consulting and Clinical Psychology. 56, 748-753.
Morin, C. M.. & Gramling, S. E. (1989). Sleep patterns and aging: Comparison of older adults with
and without insomnia complaints. Psychology and Aging, 4, 290-294.
Morin, C. M., & Ware, J. C. (1996). Sleep and psychopathology. Applied and Preventive Psychology,
5,211-224.
Morin, C. M., & Wooten. V. (1996). Psychological and pharmacological therapies for insomnia: Crit-
ical issues in assessing their separate and combined efficacy. Clinical Psychology Review, 16,
521-542.
Morin, C. M., Gaulier, B., Barry, T., & Kowatch, R. (1992). Patients' acceptance of psychological and
pharmacological therapies for insomnia. Sleep, 15,302-305.
Morin, C. M. Kowatch, R. A., Barry, T., & Walton, E. (1993). Cognitive behavior therapy for late-life
insomnia. Journal of Consulting and Clinical Psychology, 61. 137-146.
Morin, C. M., Stone, I., Trinkle, D., Mercer, J., & Remsberg, S. (1993). Dysfunctional beliefs and atti-
tudes about sleep among older adults with and without insomnia complaints. Psychology and
Aging, 8,463-467.
Morin, C. M., Culbert, J. P.. & Schwartz, S. M. (1994). Nonpharmacological interventions for insom-
nia: A meta-analysis of treatment efficacy. American Journal of Psychiatry, 151, 1172-1180.
Morin, C. M., Colecchi, C. A., Ling, W. D.. & Sood. R. K. (1995). Cognitive behavior therapy to facil-
itate benzodiazepine discontinuation among hypnotic-dependent patients with insomnia. Be-
havior Therapy. 26. 733-745.
Morin, C. M., Colecchi, C. A., Stone. J., Sood, R. K., & Brink, D. (1995). Cognitive-behavior therapy
and pharmacotherapy for insomnia: Update of a placebo-controlled clinical trial. Sleep Re-
search, 24. 303.
National Institutes of Health (NIH). (1991). Consensus development conference statement: The
treatment of sleep disorders of older people. Sleep, 14.169-177.
Nicassio, P. M., Mendlowitz. D. R.. Fussel, J. J., & Petras. L. (1985). The phenomenology of the pre-
sleep state: The development of the pre-sleep arousal scale. Behaviour Research and Therapy.
23, 263-271.
Pollak, C. P.. Perlick, D.• Linsner, J. P.. Wenston. J.. & Hsieh. F. (1990). Sleep problems in the com-
munity elderly as predictors of death and nursing home placement. Journal of Community
Health 15. 123-135.
Prinz, P. N., Vitaliano. P. P.. Vitiello, M. V., Bokan. J., Raskind. M.. Peskind, E., & Gerber, C. (1982).
Sleep, EEG and mental function changes in senile dementia of the Alzheimer's type. Neuro-
biology of Aging, 3, 361-370.
Puder, R., Lacks, P.• Bertelson, A. D., & Storandt. M. (1983). Short term stimulus control treatment
of insomnia in older adults. Behavior Therapy. 14, 424-429.
Rabins, P. V., Mace. N. 1., & Lucas, M. J. (1982). The impact of dementia on family. Journal of the
American Medical Association. 248, 333-335.
Regenstein, Q. R. (1980). Insomnia and sleep disturbances in the aged: Sleep and insomnia in the
elderly. Journal of Geriatric Psychiatry, 13. 153-171.
Reynolds, C. F., Kupfer, D. J., Taska, 1. S., Hoch, C. C., Sewitch, D. W., & Spiker, D. G. (1985). The
sleep of healthy seniors: A revisit. Sleep, 8, 20-29.
Reynolds, C. F., Kupfer, D. J., Taska, 1. S., Hoch, C. C., Spiker, D. G.. Sewitch, D. E., Zimmer, B.,
Marin, R. S., Nelson, J. P., Martin, D., & Morycz, R. (1985). EEG sleep in elderly depressed,
demented, and healthy subjects. Biological Psychiatry. 20, 431-442.
Reynolds, C. F., Kuper, D. J., Houck, P. R., Hoch, C. C., Stack, J. A., Berman, S. R., & Zimmer, B.
(1988). Reliable discrimination of elderly depressed and demented patients by electroen-
cephalographic sleep data. Archives of General Psychiatry, 45, 258-264.
Riedel. B. W.. Lichstein. K. 1.. & Dwyer. W. O. (1995). Sleep compression and sleep education for
older insomniacs: Self-help versus therapist guidance. Psychology and Aging. 10. 54-63.
Rodin. I.. McAvay. G.• & Timko. C. (1988). A longitudinal study of depressed mood and sleep dis-
turbances in elderly adults. Journal of Gerontology. 43. P45-P53.
Roehrs. T.• Lineback. w.. Zorick. F.. & Roth. T. (1982). Relationship of psychopathology to insomnia
in the elderly. Journal of the American Geriatrics Society. 30. 312-315.
Sanford. J. R. A. (1975). Tolerance of debility in elderly dependents by supporters at home: Its sig-
nificance for hospital practice. British Medicine Journal. 3. 471-173.
Schenck. C. H .• Bundlie. S. R.. Patterson. A. L.• & Mahowald. M. W. (1987). Rapid eye movement
sleep behavior disorder: A treatable parasomnia affecting older adults. Journal of the Ameri-
can Medical Association, 257, 1786-1789.
Schoicket. S. L.• Bertelson. A. D.• & Lacks. P. (1988). Is sleep hygiene a sufficient treatment for sleep
maintenance insomnia? Behavior Therapy, 19, 183-190.
Schramm. E.• Hohagan. F.. Grasshoff. U., Riemann, D., Hajak, G.• Webb. H. G.• & Berger. M. (1993).
Test-retest reliability and validity ofthe structured interview for sleep disorders according to
DSM-I1I-R. American Journal of Psychiatry, 150.867-872.
Spielman, A. J.. Saskin. P.. & Thorpy, M. J. (1987). Theatment of chronic insomnia by restriction of
time in bed. Sleep, 10, 45-56.
Vitiello, M. V.• Prinz, P. P.• Williams, D. E.• Frommlet, M. S.• & Ries, R. K. (1990). Sleep disturbances
in patients with mild-stage Alzheimer's disease. Journal of Gerontology. 45, 131-138.
Vitiello. M. V.• Bliwise. D. 1.. & Prinz. P. N. (1992). Sleep in Alzheimer's disease and the sundown
syndrome. Neurology, 42 (Suppl. 6). 83-93.
Webb. W. B. (1989). Age-related changes in sleep. Clinical Geriatric Medicine 5.275-287.
Webb. W. B, & Campbell. S. S. (1980). Awakenings and the return to sleep in an older population.
Sleep, 3, 41-46.
CHAPTER 14
Personality Disorders
BUNNY FALK AND DANIEL L. SEGAL
INTRODUCTION
In this chapter we discuss personality disorders in older adults. After a brief

look at the evolution of the DSM (Diagnostic and Statistical Manual of Mental
Disorders; American Psychiatric Association) category Personality Disorders it-
self, and description of the disorders contained therein, our focus shifts to di-
agnosis and assessment of these Axis II disorders in older adults. Thereafter, we
present viable treatment options available to the clinician. As we show, theo-
retical and research interest has varied greatly from disorder to disorder (Peter-
son, 1996), thus, treatment approaches for some disorders have a firmer
empirical foundation than others.
OVERVIEW
Why Personality Disorders?
Why should we not refer to personality disorders as character or tempera-

ment disorders? Millon (1981) pointed out that these two words, character and
temperament, are often used interchangeably with personality in the clinical as
well as popular literature. He went on to cite the derivation of the word "char-
acter" from the Greek word for "engraving," and said it was originally used to
"signify distinctive features that serve as the 'mark' of a person" (p. 7). Tempera-
ment, on the other hand, has come to mean the individual's "constitutional dis-
position" or biologically derived disposition to activity and emotionality
(Millon, 1981). Allport (1937) declared the term "personality" to be "remarkably
elastic" and "a perilous one for the psychologist to use." His concerns were
BUNNY FALK • Center for Psychological Studies. Nova Southeastern University. Fort Lauderdale.
Florida 33314. DANIEL L. SEGAL • Department of Psychology, University of Colorado at Col-
orado Springs. Colorado Springs. Colorado 80933-7150.
301
302 Bunny Falk and Daniel L. Segal
aimed at the boundaries and principal features that the concept shares with oth-
ers that are often seen as synonymous with personality.
Millon (1981) thoughtfully asked, "What then is personality?" (p. 8), and
helpfully followed with the fact that it is derived from the Greek word "persona"
for the masks used by dramatic actors. Although originally used to connote the
hidden or "pretense of appearance," the word "persona" in time came to mean
the real person, "his/her apparent, explicit, and manifest features" (p. 8). Con-
temporary use of the word "personality" has come to mean "a complex pattern
of deeply imbedded psychological characteristics that are largely unconscious,
cannot be eradicated easily, and express themselves automatically in almost
every facet of functioning" (p. 8). As such, they arise from an idiosyncratic blend
of biological dispositions and experiential learning to form the essence of the
way a person perceives, thinks, feels, and behaves. DSM-IV (American Psychi-
atric Association, 1994) defines personality traits as "enduring patterns of per-
ceiving, relating to, and thinking about the environment and oneself that are
exhibited in a wide range of social and personal contexts." Personality Disorders
are evidenced when these traits become "inflexible and maladaptive, and cause
either significant functional impairment or significant distress" (p. 630).
Just as the terms normality and psychopathology represent arbitrary posi-
tions on the continuum of mental health, the particular personality disorders
identified by the DSM-IV are somewhat arbitrary, both for what is included as
well as what is not (Tyrer, 1988). Historically, limitations made sense. Over the
past century, literally hundreds of personality disorders have been described on
the basis of clinical observations, theoretical predictions, and empirical in-
vestigations (Peterson, 1996; Millon, 1981). To reduce these many personality
disorders to a small number of the most useful, the American Psychiatric Asso-
ciation commissioned several committees (i.e., The Task Force on Nomencla-
ture and Statistics) to facilitate formulation of Axis II-Personality Disorders of
the DSM-III (American Psychiatric Association, 1980) and its successors (DSM-
III-R and DSM-IVJ. What ensued was an obvious compromise (Pincus, Frances,
Davis, First, & Widiger, 1992), not an overall vision of what it means to have a
dysfunctional personality (Millon, 1990).
It was acknowledged by the task force that personality disorders repre-
sented syndromes that were "fuzzy around the edges"; on the one hand these
disorders "shade imperceptibly into normal problems of everyday life," and on
the other, "they have few clear and distinguishable symptoms that serve as
identifying markers" (Task Force, 1976). According to Millon (1981), the task
force had hoped to differentiate personality types along the dimension of sever-
ity. As yet, no such criteria for these distinctions have been developed. How-
ever, since DSM-III, personality disorders have been grouped into three clusters
based on descriptive similarities. The DSM-IV includes ten Personality Disor-
ders. Cluster A groups the disorders in which individuals often appear odd or
eccentric: Paranoid, Schizoid, and Schizotypal Personality Disorders. Cluster B
includes Antisocial, Borderline, Histrionic, and Narcissistic Personality Dis-
orders, in which individuals appear to be dramatic, emotional, or erratic. Clus-
ter C includes the disorders in which individuals often appear fearful or
anxious: Avoidant, Dependent, and Obsessive-Compulsive Personality Disor-
ders (American Psychiatric Association, 1994). Although the descriptive focus
Personality Disorders 303
of each cluster remains intact, the disorders included have been amended
somewhat as DSMhas evolved. For example, in the DSM-III, the term "obses-
sive" was dropped in an effort to avoid confusion with the Axis I Obsessive-
Compulsive Disorder. Also, Passive-Aggressive Personality Disorder, which has
been reassigned for further study in the DSM-IV, was originally included in
Cluster C in DSM-III and DSM-Ill-R. Interestingly, DSM-IV also has listed De-
pressive Personality Disorder as a condition requiring further study.
We will not replicate the diagnostic criteria presented within the pages of
the DSM-IVhere, but it will be helpful to define and present the clinical picture
for each of the ten personality disorders included in the DSM-IV with one ad-
ditional but often neglected feature (the clinical presentation seen in the older
adult). Several researchers (Casey & Schrodt, 1989; Abrams, 1991) have sug-
gested that the "clinical lore" that some personality disorders "burn out" with
advancing age is unfounded. While it is true that markedly fewer older adults
receive diagnoses of Axis II disorders as compared to younger patients, investi-
gators have speculated that personality disorders may exist in altered form in
this population, with different symptomatology, resulting in misdiagnosis
when DSM criteria are applied (Casey & Schrodt, 1989). Kroessler (1990) noted
that "diagnostic reliability is lower" using criteria in the DSM-III for Personal-
ity Disorders because they require more inferential judgment than those for the
Axis I disorders. In an effort to improve reliability, the DSM-III-R included more
behavioral descriptors in the personality disorder guidelines, and the DSM-IV
elaborated on this behavioral emphasis by including narrative descriptions to
clarify the contextual associations of behavior (Kroessler, 1990).
DSM-IV Personality Disorders

1. Paranoid Personality Disorder
The disorder manifests itself as a pervasive pattern of distrust and suspicion

without any justification. Persons with the disorder tend not to confide in oth-
ers, refuse to give personal information, and maintain the expectation that all
others will do them harm. Suspiciousness and distrust occur in situations where
others would be hard pressed to find justification for their beliefs. The perva-
siveness of suspicion is such that even events that have nothing to do with them
will be interpreted as personal attacks. In older adults, any decline in hearing, vi-
sion, or cognitive ability may incorrectly lead to ideas of reference that others are
talking about them or threatening them in some way. Therefore, people with the
disorder are often experienced as complaining, argumentative, or hostile.
2. Schizoid Personality Disorder

The hallmark of this disorder is a preference for isolation to a point of
detachment from social relationships accompanied by a restricted range of emo-
tional expression. Such people are often experienced as aloof, cold, or indifferent
to others, but, most notably, they seem to have no desire for nor enjoyment of in-
terpersonal relationships so that they seem immune to criticism or praise. Unlike
the other two disorders included in cluster A, persons with Schizoid Personality
Disorder do not have unusual thought processes that characterize Paranoid and
Schizotypal Personality Disorders. In older adults, withdrawal from social rela-
tionships is often viewed as an accompaniment of a decline in physical stamina.
If these clinical signs were a part of a pervasive behavioral style, this note should
outweigh the assumption that what is being observed is due to normal aging.
3. Schizotypal Personality Disorder

Individuals with this disorder are described as odd, bizarre, or eccentric.
Most often such persons experience extreme discomfort with interpersonal re-
lationships; therefore, they tend to withdraw socially. Their speech and dress
are often clearly unusual. "Ideas of reference" and "magical thinking" in the
form of odd beliefs or possession of special powers such as clairvoyance or
telepathic thinking are reported. Perceptual distortions are not as extreme as
those reported by individuals with schizophrenia; people diagnosed as Schizo-
typal may report that they feel as though someone is in the room with them, but
stop short of saying that they actually see the person. Even so, others often ques-
tion their perceptions and this doubting fuels the formation of suspiciousness
and paranoid thinking. In the absence of obvious organicity, an older adult who
is unkempt, malodorous, experiences suspiciousness, paranoia, and ideas of
reference, and has few friends could be diagnosed with Schizotypal Personality
Disorder.
4. Antisocial Personality Disorder

The hallmark of the disorder is a lifelong pattern of disregard for, and fail-
ure to comply with, societal norms. Rights of others are never a consideration,
and when these rights are violated, they experience no remorse. Such people
are often perceived as aggressive because they take what they want, when they
want it, with no regard for the impact their action will have on others. Lying,
cheating, and stealing appear to be part of their nature. Several behavioral de-
scriptors of the disorder, such as aggressiveness, impulsiveness, lawlessness,
and physical fighting, clearly require physical activity (Kroessler, 1990). These
behaviors may diminish in frequency as the person's stamina and strength de-
cline with advancing age. However, Perry (1993) reported in his review oflon-
gitudinal studies of personality disorders that several researchers (Guze, 1976;
Hoke, Livori, & Perry, 1992; Martin, Cloninger, & Guze, 1982) found that felons
either incarcerated or on probation continued to meet criteria for Antisocial
Personality Disorder 6 to 9 years after their arrest. This finding may demon-
strate that even externally imposed physical limitations do not assure that the
personality disorder will remit.
5. Borderline Personality Disorder

This disorder is highlighted by extreme instability in interpersonal re-
lationships, self-image, mood, and affect. Also present is marked impulsivity,
which usually results in poor judgment and engaging in high-risk behaviors such
as substance abuse, sexual promiscuity, and self-injurious acts or suicide attempts

(Widiger & Trull, 1993). People with this disorder often complain of being chron-
ically "bored" and are experienced by others as extremely "needy" and demand-
ing. Emotionally labile, they will sometimes be described as intense, shifting from
anger to deep depression very quickly (Barlow & Durand, 1995). Snyder, Pitts,
and Gustin (1983) reported that it is "uncommon to find patients over the age of
40 with the diagnosis of borderline personality disorder" (p. 271). Often, "older
patients fulfill fewer DSM-III criteria for the disorder than they did when they
were younger and receive other diagnoses as they reach middle age" (p. 271). The
DSM-III-R (American Psychiatric Association, 1987) stated: "The manifestations
of Personality Disorders are often recognized by adolescence or earlier and con-
tinue throughout most of adult life, though they often become less obvious in
middle or old age" (p. 335). However, McCrea and Costa (1984) seemingly dis-
agreed when they hypothesized that one's character is stable throughout the life
course. Perhaps the lower incidence of the disorder in older adults "reflects more
the lack of fit of our existing diagnostic yardsticks than the lack of borderline per-
sonality disorder in old age" (Rosowsky & Gurian, 1991).
6. Histrionic Personality Disorder

People diagnosed with this disorder tend to present themselves in an over-
stated, theatrical manner, engaging in excessive emotional displays, with the
primary goal of remaining the center of attention. Their exaggerated sense of
self often prohibits any sensitivity or compassion for others. Relationships typ-
ically are superficial. Grandiose self-descriptions are not uncommon and are
usually accompanied by unreasonable expectations of special attention from
everyone. Histrionic people tend to become outraged at the mere suggestion of
a confrontation about their behavior (Beck & Freeman, 1990). In addition, they
seek reassurance continuously and become very angry or upset when others do
not give them their undivided attention. Older adults so disordered are often
described by their adult children as "acting like spoiled little children." Such
individuals, with their flirtatious and superficial style, tend to adjust poorly to
the physical changes (wrinkles, gray hair) associated with normal aging (they
do not like to look old!)
7. Narcissistic Personality Disorder

The main feature of this disorder is the exaggerated sense of self-impor-
tance a person demonstrates, to the point of being described as "grandiose" by
others. Such persons also tend to be preoccupied with themselves, lack sensi-
tivity and compassion for others, have a sense of entitlement, and express dis-
comfort in situations in which they are not surrounded by people they perceive
as being as special and privileged as they see themselves. People with the dis-
order also tend to take advantage of others to get what they want (Zimmerman,
1994). Older adults with the disorder are experienced by others as insensitive,
demanding, boorish, and selfish. Alienation of family members is not uncom-
mon after a lifetime of perceived callous disregard for, and purposeful manipu-
lation of, others in their family.
8. Avoidant Personality Disorder

People diagnosed with this disorder have an extreme sensitivity to the
opinion of others. Therefore, they avoid placing themselves in any social situa-
tion wherein they might be rejected. In essence, they reject others to avoid be-
ing rejected themselves. Such people have low self-esteem and feel inadequate
to cope with the anxiety and fearfulness associated with social relationships.
Such individuals typically are isolated across the life span.
9. Dependent Personality Disorder

For individuals with this disorder, the task of making any decision,
whether it will impact their life or determine everyday activities, is relin-
quished to others. As a result, disordered people are left with an overwhelm-
ing fear of being abandoned. Although often characterized as submissive,
passive, and timid, people with dependent personality disorder are not without
their own opinions or beliefs. However, rather than risk rejection, they do not
express their opinions and beliefs. Often after the death of their spouse, depen-
dent older adults appear helpless, unable to perform the most mundane of func-
tions after decades ofrelying on their partners to make all the decisions for the
couple. Feeling lost and vulnerable, older adults then turn to their adult chil-
dren to fill the void left by the decision maker. Such a situation is described as
"role reversal," with adult children finding themselves acting "en loco paren-
tis" for their elderly parents.
10. Obsessive-Compulsive Personality Disorder

People with this disorder are so preoccupied with details that it interferes
with functioning in several areas of their life. They manifest a pervasively rigid
and moralistic style that hinders forming interpersonal relationships. Often de-
scribed by others as "workaholics," those with this personality disorder forgo
leisure activities for the sake of productivity. Ironically, it is productivity that
suffers because the point of many an activity is lost among the rules, regula-
tions, lists, and schedules to which they scrupulously and overconscientiously
adhere. Delegation of responsibility or work to others is unheard of, usually for
fear that the task will not be completed in the "right way." Older men find it
particularly difficult to modify their approach.
DIAGNOSIS AND ASSESSMENT
Overview
The DSM-W(American Psychiatric Association, 1994) takes a view regard-
ing the course of dysfunctional patterns of inner experience and behavior (i.e.,
personality disorders) that some disorders tend to "remit with age, whereas this
appears to be less true for some other types [of disorders]" (p. 632). Recognition
of the persistent course of at least some personality dysfunction into later life
can be contrasted with the view proffered in the DSM-III-R (American Psychi-
atric Association, 1987), in which it was specifically noted that the personality
disorders become less pronounced in middle or old age.
Epidemiological and prevalence data for Axis II disorders in older adults
are scant. As noted by Spar and La Rue (1990), "Few data have been gathered on
Axis II disorders in elderly patients, in part because most of the personality dis-
orders in DSM-III-R have not been defined long enough for thorough studies to
take place" (p. 180). Indeed, prior to DSM-III, personality disorders did not have
well-operationalized or specific criteria for each type. Therefore, early investi-
gations of character pathology in older adults used classification systems that
are quite dissimilar from current DSM-III-R and DSM-IV conceptualizations
(Kroessler, 1990), thus preventing meaningful comparison of current and prior
data. Overall, it appears that prevalence rates for diagnosable personality disor-
ders in the elderly community range from 2% to 11 % from report to report (Co-
hen, 1990).
Rates are even more variable (and generally higher) when psychiatric sam-
ples are evaluated. Three retrospective studies (Casey & Schrodt, 1989; Fogel &
Westlake, 1990; Mezzich, Fabrega, Coffman, & Gavin, 1987). and one descrip-
tive study (Kunik et a1., 1993). although limited by their reliance on clinical
judgment in assigning diagnosis and the absence of reliability checks, r~ported
prevalence of personality disorders in older adults to range from 5.1 % to 24%.
Obviously, results are likely to vary depending on type of sample (Le., inpa-
tient, outpatient, medical patients), method of diagnosis (Le., clinical judgment,
structured interview, self-report), and type of design (descriptive, chart review,
longitudinal). Despite gaps in the epidemiological research base, extant data
suggest that personality disorders in the elderly are possibly more common
than previously was thought, and that a significant number of older adults suf-
fer from debilitating personality dysfunction.
Diagnosis
Diagnosis of personality disorder in the older population has been compli-

cated by several factors. One is the widely held, long-lasting (albeit erroneous)
belief that personality dysfunction either was not present or was not a serious
difficulty in older individuals. Some misdiagnoses occur because personality
disorders often produce symptoms that constitute Axis I disturbances, which
are more easily recognized and accepted by both clients and service providers
(Segal, Hersen, Van Hasselt, Silberman, & Roth, 1996). Manifestations of char-
acterological difficulties may be viewed as signs of other psychiatric disorders,
most notably depression and anxiety (Segal et al., 1996). These symptoms may,
in fact, be consequences of the pervasive social difficulties and distorted self-
images experienced by those suffering from personality dysfunction. Also,
some signs of personality disturbance (e.g., dependency, avoidance, social with-
drawal, odd thinking, emotional liability) are erroneously attributed to "old
age" or may be perceived as "normal" in the aged population. Unfortunately, di-
agnostic misconceptions can translate into confusion about the most appropri-
ate form of intervention. Too often, applied interventions target solely the more
recognized affective component of the disturbance, while the etiologically sig-

nificant underlying personality disorder is ignored.
Another obstacle to accurate diagnosis of personality disorder in older
adults is that DSM-W criteria for some personality disorders have limited rele-
vance or applicability to aged clients given their unique physical, cognitive,
and social circumstances. The need to attend to age-related issues has been
noted only recently. Just as somatic problems may confound diagnosis of Axis I
disorders, Kroessler (1990) noted similar difficulties with the diagnosis of per-
sonality disorders in older individuals. He contends that personality disorders
are most reliably described in behavioral terms and that normal aging can alter
preexisting behaviors and produce new behaviors. Lawlessness, aggressiveness,
impulsiveness, initiating physical fights, child-beating, and promiscuity require
physical activity. Consequently, some criteria may not be applicable to older
adults for biological reasons in terms of normal decreases in energy, strength,
and mobility (Kroessler, 1990). Along these lines, Fogel and Westlake (1990) use
the aging borderline personality disorder as an example, observing that "some
forms of impulsive sexual and self-injurious behaviors may become less likely,
despite the persistence of characteristic personality traits and psychodynamics"
(p. 233). Similar age bias is likely to apply to other personality types as well.
A major requirement for the diagnosis of any personality disorder is the ex-
perience of clinically significant distress or impairment in social or occupational
functioning (criterion C; DSM-W; American Psychiatric Association, 1994). As
some individuals age, they work less frequently and have fewer friends and so-
cial networks due to deaths. physical disabilities, and transportation problems.
Thus, the requirement of social and occupational impairment may preclude ac-
curate diagnosis of personality disorder in older adults whose social world is
much different from that of their younger counterparts upon whom many tax-
onomies are based. As age-related behavior change may mask presence of per-
sonality disorder, several investigators (Kroessler, 1990; Segal et al.. 1996) argue
for inclusion of age-associated criteria in the diagnostic guidelines.
Several additional factors have contributed to the lack of attention to Axis
II disorders in older adults. First, there appears to be a lack of consensus con-
cerning age-related manifestations of certain disorders, as researchers and clin-
icians have only recently been interested in psychopathology of older adults.
Second, treatment providers may lack appropriate knowledge about how per-
sonality disorders manifest themselves in an older patient. Consequently, their
initial assessment measures may fail to detect this component. Third, diverse
service providers to older individuals may be biased against diagnosing per-
sonality disorders or defining problems as characterological (Rose, Soares, &
Joseph, 1993). Rose and colleagues suggest that the inflexibility and resistance
to intervention attributed to individuals carrying an Axis II diagnosis often
make the client seem "hopeless" and service providers feel "helpless." Profes-
sionals may also feel angry, frustrated, and manipulated by personality disor-
dered elders and they may react by withdrawing or blaming the client.
Unfortunately, despite the discomfort of service providers and the bias against
diagnosing Axis IT disorders, older clients with personality disorders exist and
are in need of support and intervention. Fourth, there may be inadequate case-
finding strategies for personality-disordered elders who view their characteris-
tic modes of thinking and behaving as ego-syntonic and do not recognize a

problem. Consequently, many older adults with significant character pathology
simply see little reason to seek mental health services.
Several case reports have appeared in the literature documenting the
unique diagnostic and intervention challenges faced by mental health profes-
sionals. Siegel and Small (1986) document these challenges in a case descrip-
tion of borderline personality disorder. More recently, case examples of
histrionic, borderline, and avoidant personality disorders in old age have been
presented (Rose et a1., 1993). Systematic evaluation to develop profiles of the
manifestations of each disorder in the aged has not yet evolved. Longitudinal
studies following personality-disordered individuals into later life are needed.
Such studies would enable investigators to assess changes over time in symp-
tom patterns and personality characteristics.
Assessment
The original Minnesota Multiphasic Personality Inventory (MMPI; Hath-

away & McKinley, 1983), its revision, the MMPI-2 (Hathaway, & McKinley,
1989), the Millon Clinical Multiaxial Inventory III (MCMI-III; Millon, 1994),
and the Coolidge Axis II Inventory (CAT!, Coolidge, 1993) are among the most
commonly utilized objective methods for measuring personality styles, disor-
ders, and clinical syndromes (Segal et a1., 1996). These instruments are dis-
cussed below.
Minnesota Multiphasic Personality Inventory (MMPI)

Description. The MMPI was not designed or standardized to measure
functioning in older adult populations (Segal et a1., 1996). In fact, individuals
over age 65 were not included in the normative sample (Colligan & Offord,
1992). The restandardization process involved in constructing the MMPI-2
(Hathaway & McKinley, 1989) incorporated persons up to 85 years of age. How-
ever, norms for older adults are noticeably absent from resource books (Graham,
1990), although separate MMPI-2 norms for men and women are provided and
an adolescent version of the instrument is available.
MMPI and Older Adults. As the original MMPI did not include persons
over 65 in the normative group, several investigators have examined its effec-
tiveness in normal, nonpatient, older samples (e.g., Colligan & Offord, 1992;
Colligan, Osborne, Swenson, & Offord, 1984; Greene, 1980; Harmatz & Shader,
1975; Leon, Gillum, Gillum, & Gouze, 1979). In their review of these studies,
Taylor, Strassberg, and Turner (1989) identified several trends. They noted that
nonpsychiatric older respondents generally displayed substantial elevations
(approximately one standard deviation) on Scales 1 (Hypochondriasis), 2 (De-
pression), and 3 (Hysteria). Smaller elevations were reported for Scales K and
o (Social Introversion) when compared to the standard adult MMPI norms.
Application of the MMPI has also been investigated in older psychiatric
populations (e.g., Dye, Bohm, Anderten, & Cho, 1983; Pennington, Peterson, &
Barber, 1979; Rusk, Hyerstay, Calsyn, & Freemen, 1979; Weiss, 1973). Taylor
and colleagues (1989) concluded from the collective findings that the most
common elevations were obtained on Scales 1 and 2, a finding similar to the
normal samples of older adults. In addition, elevations of 11/2 standard devia-
tions were found on Scales 3 and 8 (Schizophrenia), while deviations of about
+1 standard deviation were noted for Scales F, 4 (Psychopathic Deviate),
6 (Paranoia), and 7 (Psychasthenia). Taylor and colleagues (1989) caution, how-
ever, that most results were based on either extremely small samples or highly
specific clinical groups, thus limiting generalizability. The purpose of their ef-
fort was to identify norms for a nonclinical elderly sample and to assess the dis-
criminant validity of the MMPI (clinical versus community elderly). Results
suggested that the MMPI discriminated well between the two groups with sig-
nificant differences reported on 9 of 13 scales. Overall the MMPI was consid-
ered valid for use with older populations.
Clearly, utility of the MMPI and the MMPI-2 in older adult samples has yet
to be unequivocally ascertained. For example, questions about interpretation of
elevations on Scales 1, 2, and 3 have been raised in light ofthe confounding in-
fluences of biological maturation. Given the likelihood of an increase in physi-
cal problems in the elderly, several investigators urge caution when interpreting
elevations in Scale 2 (Bolla-Wilson & Bleecker, 1989) and Scales 1 and 3 (Taylor
et a1., 1989). No research specifically applying the MMPI to older inpatient
groups or to groups with specific personality disorders has been located. In ad-
dition, the MMPI-2 has not been empirically validated specifically in the older
population (Segal et a1., 1996). Finally, it should be pointed out that the MMPI
scales employed in the studies cited are not measures of DSM-III-R or DSM-W
personality disorders, but rather of personality traits, symptom profiles, and
Axis I disorders. Further, while personality scales have been derived from the
MMPI (see Morey, Waugh, & Blashfield, 1985), validation studies specific to an
older population are lacking.
Millon Clinical Multiaxiallnventory (MCMI)

Description. The original MCMI (Millon, 1983) was revised and reintro-
duced as the MCMI-II (Millon, 1987) and most recently as the MCMI-III (Millon,
1994). The MCMI-III is a self-report inventory designed to assess and diagnose
DSM-IV-related personality disorders. Widely used in clinical and research
contexts, its taxonomy is more consistent with the DSM system than the origi-
nal MCMI. The MCMI-III has 24 scales (14 personality pattern scales and 10
Axis I scales) and is constructed to distinguish between Axis I and Axis II diag-
noses, as well as to assess level of severity of all syndromes (Millon, 1992).
MCMI and Older Adults. Application of the MCMI to older psychiatri-

cally impaired adults has been explored in only one study, and norms for this
measure are unavailable for nonpsychiatric elders (Segal et al., 1996). Hyer and
Harrison (1986) administered the instrument to elderly psychiatric inpatients,
and reported that incidence rates of dependent and avoidant personality disor-
ders were highest in this older group. In contrast, histrionic, narcissistic, and
antisocial personality disorders had the lowest rates. These investigators char-
acterized the latter disorders as "higher intensity personality styles" and con-
cluded that "with age, there appears to be a mellowing of higher energy per-
sonality types" (p. 408). The paucity of studies clarifying age differences
between younger and older adults, and the lack of normative data for older
adults, are problems to be addressed by future research.
Coolidge Axis II Inventory (CATI)

Description. The CATI (Coolidge, 1993) is a true-false, self-report inven-
tory originally developed to assess personality disorders according to the diag-
nostic criteria of the DSM-III-R. It has since been updated to match DSM-W
criteria for all personality disorders. The inventory contains 14 personality dis-
order scales, including the sadistic and self-defeating personality disorders,
with items from DSM-III-R designed to match all the unique criteria for person-
ality disorder diagnosis detailed in the DSM-w' The CATI also provides scores
on several Axis I scales (e.g., Brain Dysfunction, Depression, Anxiety, and
PTSD). Excellent test-retest reliability (.90) has been established for the CATI,
as well as moderate internal consistency (.76). With regard to validity, a 50%
concordance rate with clinical diagnoses for 24 personality disordered patients
was reported (Coolidge & Merwin, 1992).
CATI and Older Adults. Coolidge, Bums, Nathan, and Mull (1992) ad-
ministered the CATI to normal younger (mean age 24.0 years) and older (mean
age 69.4 years) individuals and found that for Axis I syndromes, older adults
were significantly less anxious and showed more signs of brain damage, while
reporting no differences on the depression scale. As for Axis II, the older adults
scored significantly lower on antisocial, borderline, histrionic, narcissistic,
paranoid, passive-aggressive, schizotypal, sadistic, and self-defeating scales
than their younger counterparts. By contrast, older adults were significantly
more obsessive-compulsive and schizoid. No group differences were obtained
for avoidant or dependent personality disorder scales. Coolidge and colleagues
(1992) note that, in general, the older sample scored lower on items associated
with impulsivity and endorsed items consistent with restricted affectivity.
These investigators attributed the nonsignificant finding for depression to the
lack of somatic items on that particular scale. As with the MCMI, investigations
of age differences with clinical samples have been conducted infrequently.
Also, normative data for an older adult population of psychiatric patients has
not been collected or examined.
Comparisons of the MMPI, MCMI, and CATI

MMPI and MCMI. Several studies have compared the MMPI and MCMI for
Axis I disorders (see Libb, Murray, Thurstin, & Alarcon, 1992; Patrick, 1988).
With regard to the Axis II disorders, controversy surrounds the fact that the
MCMI is derived from Millon's personality/psychopathology theory (Segal et
al., 1996). Initially, conceptual differences between Millon's theory of psy-
chopathology and nosology and DSM-IIItypology called into question the valid-
ity of the MCMI as a measure of DSM-III personality disorders (see Widiger,
Williams, Spitzer, & Francis, 1985); however, with updates in the new MCMI-III,
the convergence between Millon's taxonomy and the DSM is appreciably strong.
Concurrent validity investigations generally have shown a modest degree
of convergence between the MCMI and personality scales derived from the
MMPI (McCann, 1989; Morey & LeVine, 1988; Streiner & Miller, 1988). A recent
validity study with the updated MCMI-II and MMPI personality disorder scales
demonstrated that, relative to the original MCMI, the updated MCMI-II gener-
ated higher concordance rates for antisocial and passive-aggressive disorders,
but still failed to reach significant convergence on the obsessive-compulsive
scale (McCann, 1991). None of these studies, however, specifically targeted
older adults; therefore, the concurrent validity of the MCMI and the MMPI is
presently unknown for this population.
MCMI and CAT!. Coolidge and Merwin (1992) compared the CAT! and
the MCMI-II in a sample of psychiatric outpatients (mean age 38.0 years) clini-
cally assessed by their therapists to have a personality disorder. Similar to a
previous MCMI-MMPI validation study (McCann, 1991), correlations for the
obsessive-compulsive personality disorder were extremely low. Based on a cri-
terion analysis of this scale, the investigators suggested that diagnostic criteria
coverage of the MCMI-II was incomplete as only five ofthe nine stated DSM-III-R
criteria were addressed. Coolidge and Merwin (1992) concluded that the low
correlation was due to lack of adherence of the MCMI to DSM-III-R criteria upon
which the CATI is based. In contrast, for the disorders for which the MCMI-ll's
adherence to DSM-III-R criteria was high, correlations between the two inven-
tories were stronger. Overall, the MCMI-II diagnosed more subjects as having
personality disorders than did the CAT!.
Other Assessment Instruments and Older Adults

Several additional devices also have been designed to assess DSM-IV per-
sonality disorders; an example is the Personality Diagnostic Questionnaire-4
(PDQ-4; Hyler, 1994), an 85-item self-administered, true/false inventory that
taps the ten standard DSM-IV personality disorders. Several popular structured
interviews that yield DSM-JV diagnoses include the Structured Clinical Inter-
view for DSM-IV Axis II Personality Disorders (SCID-I; First, Gibbon, Spitzer,
Williams, & Benjamin, 1997), the International Personality Disorder Examina-
tion (IPDE; Loranger et aJ., 1994), and the Structured Interview for DSM-IVPer-
sonality (SIDP-IV; Pfohl, Blum & Zimmerman, 1995).
As is the case with instruments discussed earlier, application of the afore-
mentioned measures to older individuals is sparse. In two studies (Abrams,
Alexopoulos, & Young, 1987; Abrams, Rosendahl, Card, & Alexopoulos, 1994)
the PDE was administered to small samples of older adults. The earlier study
compared 15 normal controls to 21 recovered depressives and found that only
two participants met criteria for a personality disorder, but no reliability esti-
mates for the PDE were reported. The latter study used the PDE to assess 30 re-
covered depressed elders and reliability estimates between two raters were
calculated. Results suggested a high level of interrater reliability (range. 75 to
1.0; mean .94) for all personality disorders except histrionic (.23). Schneider,
Zemansky, Bender, and Sloane (1992) assessed personality traits using the
SCID-II in a small sample of euthymic elders with a history of depression. To in-
vestigate the relationship between personality disorder and treatment outcome
for late-life depression, Thompson, Gallagher, and Czirr (1989) obtained Axis
II formulations by using the Structured Interview for DSM-IIIPersonality (SIDP;
Pfohl, Stangl, & Zimmerman, 1983) in a sample of 79 elders. While interrater re-
liability for comparisons across all twelve personality classifications was high
(kappa = .79), individual estimates were not reported.
Comment
All of the frequently administered structured interviews for DSM personal-
ity disorders (SCID-II, IPDE, SIDP-IV) have been applied to older populations,
but definitive comparisons have been difficult to make because of small sample
sizes, variant settings, and limited reliability, not to mention the fact that these
new versions have been published only recently. In the absence of empirical ver-
ification, it cannot be assumed that structured interviews for Axis II disorders
have acceptable operating characteristics for this unique population. As for self-
report devices, normative and reliability data are limited for the PDQ-R (Hyler &
Reider, 1987). For the MMPI, several large-scale studies have provided norma-
tive data for older adults. Results have clearly shown that older individuals re-
spond in ways substantially different from their younger counterparts. However,
such clinically significant information has not been incorporated into standard
use of the instrument, as has been done with norms for men, women, and ado-
lescents. Despite availability of these data, clinicians employing the MMPI with
older adults continue to rely on clinical intuition to determine significance of
profile elevations. Moreover, although normative data for the MMPI exist, nei-
ther the MMPI-2 nor the MMPI personality disorder scales developed by L. C.
Morey and colleagues (1985) have been adequately researched in the elderly.
The MCMI and CATI self-report personality instruments have been applied
to older adults, albeit minimally. Hyer and Harrison (1986) administered the
MCMI to a group of older inpatients and reported incidence rates, although
comparisons to matched normal or younger patients were not included in their
investigation. For the CATI, only one report examined age difference between
normal younger and older respondents (Coolidge et al., 1992).
Comparisons among widely employed measures to assess their concurrent
validity with older adults have been undertaken only recently. A recent com-
parison between MCMI-II and MMPI personality disorder scales in an adult
sample has yielded encouraging results (McCann, 1991). Investigating this re-
lationship in an older sample should not be delayed. Two studies have ex-
plored the concurrent validity of MCMI-II with the CATI, with one specifically
targeting older mentally ill inpatients (Silberman, Roth, Segal, & Burns, 1997).
Median concordance (correlation between raw score sums) in this study was
.55, with a range of -.13 (schizoid) to .88 (borderline). Results for the older
sample were also generally poorer than those obtained in the younger group
(Coolidge & Merwin, 1992). These findings point to the need for specific vali-
dation in older samples who seem to manifest character disorders differently
from younger adults.
Little attention has been accorded to systematic exploration of the rela-

tionship between Axis I and Axis II disorders, specifically within the older pop-
ulation. As shown by Mavissakalian and colleagues (Mavissakalian & Hamann,
1986; Mavissakalian & Hamann, 1988; Mavissakalian, Hamann, & Jones, 1990;
Mavissakalian, Hamann, Haidar, & de Groot, 1993), personality disorders and
many Axis I disorders (e.g., generalized anxiety, panic/agoraphobia, and obses-
sive-compulsive) can be linked, providing important conceptual clarification of
the Axis I conditions. While some of Mavissakalian's work included older sub-
jects, data were not separated for older and younger groups. There is still an un-
met need for understanding of the characterological component to Axis I
presentations in older patients. Research is needed to shed more light on the re-
lationships between Axis I and Axis II disorders so as to yield more effective
treatment strategies.
TREATMENT
Overview
Overall, inadequate assessment and diagnosis are major barriers to the

treatment phase for personality dysfunction in older adults. Elder-specific as-
sessment measures have yet to be developed and validated; thus, knowledge as
to how personality disorders in older adults are identified and dealt with by
service providers is limited. Because of the unique characteristics and differ-
ing presentation of older individuals with personality dysfunction, clinicians
must be cognizant of specific variables associated with aging, as well as corre-
lates of personality disorders in the elderly. Some investigators, however, posit
that those with personality disorders seem to respond poorly to most forms of
therapy (Reich & Green, 1991; Shea et a1., 1990). In addition, because of impre-
cise and overlapping criteria used to describe these disorders (Blashfield &
Breen, 1989; Nurnberg et al., 1991; Oldham et al., 1992), multiple diagnoses
seem almost inevitable (e.g .. Herbert, Hope. & Bellack. 1992; Kavoussi & Siever,
1992; Schneier, Spitzer, Gibbon. Fyer, & Leibowitz. 1991).
'freatment of the Specific Disorders

Paranoid Personality Disorder
Clinicians are offered little in the way of treatment proposals for this dis-
order (Adler, 1990) except that it is "virtually a given that such individuals do
not fare well in therapy" (Peterson, 1996, p. 385). The therapist is sure to be
viewed with the same suspicion as everyone else (Bullard, 1960), and thera-
peutic alliance is difficult to form. Lack of insight into the internal origins of
their suspicions fosters the notion that it is others who have "the problem." El-
lison and Adler (1990) report that psychotropic medications used to treat posi-
tive symptoms of schizophrenia offer a viable treatment option, in that they
reduce levels of suspicion in some patients.
Schizoid Personality Disorder

Treatment options for this disorder "remain a puzzle because so few people
who warrant the diagnosis enter the mental health system" (Peterson, 1996,
p. 385). In older adults, entree into the medical system is usually when pathol-
ogy is first addressed. Thus, success is hardly expected by most caregivers, and
the low expectations probably account for the paucity of investigations into ef-
fective treatment. Links with schizophrenia suggest, however, that behaviorally
oriented social and life skills training offer the most likely treatment options.
Schizotypal Personality Disorder

The social awkwardness and anxiety that characterize this personality style
should be considered when planning treatment for individuals so diagnosed.
Although treatment protocols have not been systematically investigated
(Mehlum et al., 1991), the disorder's proposed relationship to schizophrenia
highlights the need to limit the patient's exposure to stressful situations (Peter-
son, 1996). When older adults so diagnosed lose the ability to live indepen-
dently, their "odd" or "eccentric" peculiarities are an unwelcome imposition on
others. Caregivers may look to psychotropic medications that prove useful in
treating prominent delusions or hallucinations to quiet (albeit unsuccessfully)
these "strange" behaviors. Bellack and Hersen (1985) and others (e.g., O'Brien,
Trestman, & Siever, 1993) have suggested social skills training as a means to im-
prove socialization and reduce isolation.
Antisocial Personality Disorder

Early intervention with persons at risk for developing the disorder in adult-
hood is the most successful treatment approach. This means that children at
risk need to be identified and interventions implemented before the disorder
manifests itself in early adulthood. Clinicians are, for the most part, pessimistic
about treatment for patients who do not perceive themselves as having any
problems (Patterson, 1982), a trait prominent in individuals with Antisocial
Personality Disorder. Lack of early intervention usually results in clinicians' de-
ferring to incarceration as a means of limiting future antisocial behavior (Bar-
low & Durand, 1995).
Borderline Personality Disorder

Treatment with people diagnosed with this disorder would be problematic
and challenging even if their dropout rate from therapy was not so high (Gunder-
son et al., 1989). Several investigators (Aronson, 1989; Higgit & Fonagy, 1992)
have reported that inability to achieve insight, as well as the inability to focus on
the self and monitor how they think and feel, limits the effectiveness of insight-
oriented approaches. Cognitive-behavioral treatment formulations (Beck &
Freemen, 1990; Fleming & Pretzer, 1990) teach the borderline individual to iden-
tify troublesome thoughts and feelings and then gain mastery of them. Westin
(1991) points out that a blend of cognitive-behavior and object-relations strategies
produces an effective approach, "because what they do in effect is teach the adult
individual what most children learn while growing up" (Peterson, 1996, p. 394).
Histrionic Personality Disorder

Disappointingly, there is a paucity of research into the effectiveness of pro-
posed treatment approaches for this disorder (Dulit, Marin, & Frances, 1993;
Quality Assurance Project, 1991). Treatment usually takes a dual track: sup-
portive, to foster growth through nurturing the individual to trust and relate bet-
ter to others, and behavioral, to instruct the individual in more appropriate
ways to ask for their wants and needs (Beck & Freeman, 1990).
Narcissistic Personality Disorder

Millon (1981) reports that typically, narcissistic individuals do not seek out
treatment for their dysfunctional attitudes and behaviors, which are ego-syn-
tonic. However, many narcissistic individuals experience depressed mood; they
view this as ego-dystonic and seek treatment. Much of the treatment literature
comes from a psychodynamic perspective, but even here, there is disagreement
as to the effectiveness of treatment (Aronson, 1989; Glasser, 1992). Ofthe object
relations school, Kernberg (1975) takes the position that narcissism can be suc-
cessfully treated psychoanalytically. Kohut (1971,1977) disagrees and argues
that psychoanalysis is of limited usefulness. Cognitive-behaviorists aim to im-
prove individuals' ability to see themselves in a more complex and realistic
way, as opposed to either inflated or diminished (Beck & Freeman, 1990).
Avoidant Personality Disorder

Treatment strategies aimed at placing avoidant individuals in more situa-
tions that will allow them to challenge negative associations with social inter-
actions have been developed by behavioral and cognitive-behavioral theorists
(Alden, 1989; Alden & Caperol, 1993; Heimberg & Barlow, 1991; Renneberg,
Goldstein, Phillips, & Chambless, 1990). Proceeding carefully, the therapy fo-
cuses on changing individuals' thoughts about themselves and the world and
identifying and gathering evidence to support these notions. Social skills train-
ing is an integral part of the treatment protocol (Stravynski, Lesage, Marcouiller,
& Elie, 1989).
Dependent Personality Disorder

Cognitive-behavioral strategies that include social skills training, assertive-
ness training, and learning to challenge automatic thoughts about abandonment
have been demonstrated as being effective (Beck & Freeman, 1990; Turkat &
Carlson, 1984). However, Millon (1981) cautions that dependent individuals of-
ten appear agreeable to and compliant with every suggestion that the clinician
makes. Reports of "great success" at times represent attempts to please the ther-
apist, rather than representing accurate outcome data.
Obsessive-Compulsive Personality Disorder

Insight-oriented therapy has long targeted the fears that seem to underlie the
need for orderliness (Peterson, 1996). In addition, behavioral interventions such
as systematic desensitization, relaxation training, and distraction techniques (Ric-
ciardi et aI., 1992; Steketee, Foa, & Grayson, 1982) increase the individual's toler-
ance for anxiety experienced while exploring these fears and compulsions.
SUMMARY
Only recently have psychologists recognized the importance of evaluating

specific diagnostic, assessment, and treatment strategies for elders with signifi-
cant personality dysfunction. Accurate diagnosis of character pathology has
been hampered by numerous factors. Given the unique physical, cognitive, and
social factors encountered by this segment of society, some DSM-W criteria may
be inadequate for older adults. The decline in prevalence of some disorders
(e.g., borderline, histrionic) may not be due to a "mellowing" or maturation of
the individuals, but rather the inability ofthe current system to identify age-re-
lated manifestations of the disorders. Future research must clarify the clinical
presentations, develop profiles, and identify age-related criteria that many in-
vestigators have reported as lacking in older adults. Subsequent versions of the
DSM must acknowledge the existing age bias and provide age-associated crite-
ria to better fit clinical presentation of the disordered older adult. Also, longi-
tudinal studies are needed to follow younger individuals with personality
disorders into later life; such investigations represent the only strategy for di-
rectly assessing and clarifying intraindividual changes over time in these dis-
orders that may hamper accurate diagnosis (Segal et aI., 1996). Treatment
strategies derived from the clarified picture of the personality-disordered older
adult obviously will result in more efficient and effective outcomes.
REFERENCES
Abrams. R. C. (1991). The aging personality. International Journal of Geriatric Psychiatry, 6, 1-3.
Abrams, R. C., Alexopoulos, G. S.. & Young. R. C. (1987). Geriatric depression and DSM-III-R per-
sonality criteria. Journal of the American Geriatrics Society. 35, 383-386.
Abrams, R. C., Rosendahl, E.. Card. C., & Alexopoulos, G. S. (1994). Personality disorder correlates
of late and early onset depression. Journal of the American Geriatrics Society, 42, 727-731.
Adler, D. A. (1990). Personality disorders: Treatment of the nonpsychotic chronic patient. New Di-
rection for Mental Health Services, 47, 3-15.
Alden. L. E. (1989). Short-term structured treatment for avoidant personality disorder. Journal of
Consulting and Clinical Psychology. 57, 756-764.
Alden. 1. E.. & Caperol, M. J. (1993). Avoidant personality disorder: Interpersonal problems as pre-
dictors oftreatment response. Behavior Therapy, 24, 357-376.
Allport, G. W. (1937). Personality: A psychological interpretation. New York: Holt.
(3rd ed.). Washington. DC: Author.
(3rd ed., rev.). Washington. DC: Author.
Aronson, T. A. (1989). A critical review of psychotherapeutic treatments of the borderline person-
ality: Historical trends and future directions. Journal of Nervous and Mental Disease. 177,
511-528.
Barlow, D. H .. & Durand, V. M. (1995). Abnormal psychology: An integrative approach. Pacific
Grove, CA: Brooks/Cole.
Beck, A. T., & Freeman. A.(1990). Cognitive therapy of personality disorders. New York: Guilford.
Bellack, A. S., & Hersen, M. (Eds.). (1985). Dictionary of behavior therapy techniques. New York:
Pergamon.
Blashfield, R. K., & Breen, M. J. (1989). Face validity of DSM-III-R personality disorders. American
Journal of Psychiatry, 146, 1575-1579.
Bolla-Wilson, K, & Bleecker, M. L. (1989). Absence of depression in elderly adults. Journal of
Bullard, D. M. (1960). Psychotherapy of paranoid patients. Archives of General Psychiatry, 2,
137-141.
Casey, D. A., & Schrodt, C. J. (1989). Axis II diagnoses in geriatric inpatients. Journal of Geriatric
Psychiatry and Neurology, 2, 87-88.
Cohen, G. D. (1990). Psychopathology and mental health in the mature and elderly adult. In J. E.
Birren & K W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 359-371). San
Diego, CA: Academic.
Colligan, R. C., & Offord, K P. (1992). Age, stage, and the MMPI: Changes in response patterns over
an 85 year age span. Journal of Clinical Psychology, 48, 476-493.
Colligan, R. C., Osborne, D., Swenson, W. M., & Offord, K P. (1984). The MMPI: Development of
contemporary norms. Journal of Clinical Psychology, 40, 100-107.
Coolidge, F. L. (1993). Coolidge Axis II Inventory manual. Clermont, FL: Synergistic Office Solu-
tions.
Coolidge, F. 1., & Merwin, M. M. (1992). Reliability and validity of the Coolidge Axis II Inventory:
A new inventory for the assessment of personality disorders. Journal of Personality Assess-
ment, 59, 223-238.
Coolidge, F. L., Burns, E. M., Nathan, J. H., & Mull, C. E. (1992). Personality disorders in the elderly.
Clinical Gerontologist, 12,41-55.
Dulit, R. A., Marin, D. B., & Frances, A. J. (1993). Cluster B personality disorders. In D. 1. Dunner
(Ed.), Current psychiatric therapy (pp. 405-411). Philadelphia: Saunders.
Dye, C. J., Bohm, A., Anderten. P., & Cho, D. W. (1983). Age group differences in depression on
MMPI-D scale. Journal of Clinical Psychology, 39, 227-234.
Ellison, J. M., & Adler, D. A. (1990). A strategy for the pharmacotherapy of personality disorders.
New Directions for Mental Health Services, 47, 43-63.
First, M. B., Gibbon, M., Spitzer, R. 1., Williams, J. B. W., & Benjamin. 1. S. (1997). Structured Clin-
ical Interview for DSM-IV Axis II Personality Disorders (SCID-II), Washington, DC: American
Psychiatric Press.
Fleming, B., & Pretzer, J. L. (1990). Cognitive-behavioral approaches to personality disorders.
Progress in Behavior Modification, 25, 119-151.
Fogel, B. S., & Westlake, R. (1990). Personality disorder diagnosis and age in inpatients with major
depression. Journal of Clinical Psychiatry, 51, 232-235.
Glasser, M. (1992). Problems in the psychoanalysis of certain narcissistic disorders. International
Journal of Psychoanalysis, 73, 493-503.
Graham, J. R. (1990). MMPI-2: Assessing personality and psychopathology. New York: Oxford Uni-
versity Press.
Greene, R. L. (1980). The MMPI: An interpretive manual. New York: Grune & Stratton.
Gunderson, J. G., Frank, A. F., Ronningstam, E. F., Wachter, S., Lynch, V. J., & Wolf, P. J. (1989). Early
discontinuance of borderline patients from psychotherapy. Journal of Nervous and Mental
Disease, 177, 38-42.
Guze, S. B. (1976). Criminality and psychiatric disorders. New York: Oxford University Press.
Harmatz, J. S., & Shader, R. E. (1975). Psychopharmacological investigations in healthy elderly
volunteers: MMPI depression scale. Journal of the American Geriatrics Society, 23,
350-354.
Hathaway. S. R.. & McKinley. J. C. (1983). The Minnesota Multiphasic Personality Inventory man-
ual. New York: Psychological Corporation.
Hathaway. S. R.. & McKinley. J. C. (1989). MMPI-2: Minnesota Multiphasic Personality Inventory-2:
Manual for administration and scoring. Minneapolis: University of Minnesota Press.
Heimberg. R. G.. & Barlow. D. H. (1991). New developments in cognitive-behavioral therapy for so-
cial phobia. Journal of Clinical Psychology, 52. 21-30.
Herbert. J. D.. Hope. D. A.• & Bellack. A. S. (1992). Validity of the distinction between generalized
social phobia and avoidant personality disorder. Journal of Abnormal Psychology, 101.
332-339.
Higgitt. A.• & Fonagy. P. (1992). Psychotherapy of borderline and narcissistic personality disorder.
British Journal of Psychiatry, 161. 23-43.
Hoke. L. A.• Livori. P. W.• & Perry. J. C. (1992). Mood and global functioning in borderline personal-
ity disorder: Individual regression models for longitudinal measurements. Journal of Psychi-
atric Research. 26.1-16.
Hyer. 1.. & Harrison. W. R. (1986). Later life personality model. Clinical Gerontologist. 5. 399-416.
Hyler. S. E. (1994). Personality Diagnostic Questionnaire. 4th edition {PDQ-4}. New York: New York
State Psychiatric Institute.
Hyler. S. E.• & Reider. R. O. (1987). PDQ-R: Personality Diagnostic Questionnaire-Revised. New
York: New York State Psychiatric Institute.
Kavoussi. R. J.• & Siever. L. J. (1992). Overlap between borderline and schizotypal personality dis-
orders. Comprehensive Psychiatry, 33. 7-12.
Kernberg. O. (1975). Borderline conditions and pathological narcissism. New York: Jason Aronson.
Kohut. H. (1971). The analysis of the self. New York: International Universities Press.
Kohut. H. (1977). The restoration of the self. New York: International Universities Press.
Kroessler. D. (1990). Personality disorders in the elderly. Hospital and Community Psychiatry, 41.
1325-1329.
Kunik. M. E.. Muisant. B. H.. Rifai. A. H.• Sweet. R. A.. Pasternak. R.. Rosen, J.• & Zubenko, G. S.
(1993). Personality disorders in elderly inpatients with major depression. American Journal of
Geriatric Psychiatry, 1,38-45.
Leon, G. R., Gillum, B., Gillum, R.. & Gouze. M. (1979). Personality stability and change over a 30
year period middle age to old age. Journal of Consulting and Clinical Psychology, 47. 515-524.
Libb, J. W.. Murray. J., Thurstin, H., & Alarcon, R. D. (1992). Concordance ofthe MCMI-II, the MMPI.
and Axis I discharge diagnosis in psychiatric inpatients. Journal of Personality Assessment,
58, 580-590.
Loranger, A. W., Sartorius, N., Andreoli, A., Berger, P.. Channabassavanna, S. M.. Coid, B., Dahl,
A.. Diekstra. R. F. W.• Fegeson, B.. Jacobsberg, L. B.. Mombour. W., Pull, C.. Ono, Y., & Regier,
D. (1994). The International Personality Disorder Examination: The World Health Organiza-
tion/ Alcohol, Drug Abuse, and Mental Health Administration international pilot study of per-
sonality disorders. Archives of General Psychiatry, 51, 215-224.
Loranger. A. W., Susman. V. L.• Oldham, J. M.. & Russakof. L. M. (1987). The Personality Disorder
Examination: A preliminary report. Journal of Personality Disorders. 1. 1-13.
Martin. R. L.. Cloninger, C. R., & Guze, S. B. (1982). The natural history of somatization and sub-
stance abuse in women criminals: A six year follow-up. Comprehensive Psychiatry, 23,
528-537.
Mavissakalian, M.• & Hamann. M. S. (1986). Correlates of DSM-III personality disorder in agora-
phobia. Comprehensive Psychiatry. 27, 471-479.
Mavissakalian. M.• & Hamann. M. S. (1988). Correlates of personality disorders in panic disorder
and agoraphobia. Comprehensive Psychiatry, 29, 535-544.
Mavissakalian. M.• Hamann. M. S .• & Jones. B. (1990). Correlates of DSM-III-R personality disorder
in obsessive-compulsive disorder. Comprehensive Psychiatry. 31, 481-489.
Mavissakalian. M.• Hamann. M. S .• Haidar. S. A.• & de Groot. C. M. (1993). DSM-III personality dis-
orders in general anxiety. panic/agoraphobia, and obsessive-compulsive disorders. Compre-
hensive Psychiatry, 34, 243-248.
McCann. J. T.• (1989). MMPI personality scales and the MCMI: Concurrent validity. Journal ofClin-
ical Psychology, 45, 365-369.
McCann. J. T. (1991). Convergent and discriminant validity ofthe MCMI-II and MMPI personality dis-
order scales. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 3, 9--18.
McCrae, R R, & Costa, P. T. (1984). The search for growth or decline in personality. In R R Mc-
Crae & P. T. Costa (Eds.), Emerging lives, ednduring dispositions: Personality in adulthood (pp.
13-28). Boston: Little, Brown.
Mehlum, L., Friis, S .• Irion, T., Johns, S .• Karterud, S .• Vaglum. P.• & Vaglum, S. (1991). Personality
disorders 2-5 years after treatment: A prospective follow-up study. Acta Scandinavica. 84,
72-77.
Mezzich. T. E., Fabrega. H., Coffman, G. A., & Gavin, Y. (1987). Comprehensively diagnosing geri-
atric patients. Comprehensive Psychiatry, 28. 68-76.
Millon, T. (1981). Disorders of Personality: DSM-III, Axis II. New York: Wiley.
Millon, T. (1983). Millon Clinical Multiaxial Inventory. Minneapolis, MN: Interpretive Scoring Systems.
Millon, T. (1987). Millon Clinical Multiaxial Inventory II {MCMI-IJ} manual. Minneapolis, MN: Na-
tional Computer Systems.
Millon, T. (1990). Toward a new personology: An evolutionary model. New York: Wiley-Inter-
science.
Millon, T. (1992). Millon Clinical Multiaxial Inventory: I & II. Journal of Counseling and Develop-
ment, 70,421-426.
Millon, T. (1994). Millon Clinical Multiaxial Inventory III (MCMI III) manual. Minneapolis, MN: Na-
tional Computer Systems.
Morey, L. C., Waugh, M. H., & Blashfield, R. K. (1985). MMPI scales for DSM-III personality disor-
ders: Their derivation and correlates. Journal of Personality Assessment, 49, 245-256.
Morey, L. C., & LeVine, D. J. (1988). A multi-trait. multimethod examination of Minnesota Multi-
phasic Personality Inventory (MMPI) and Millon Clinical Multiaxial Inventory (MCMI). Jour-
nal of Psychopathology and Behavioral Assessment, 10, 333-344.
Nurnberg, H. G., Raskin, M., Levine, P. E., Pollack, Soo Siegel, 0., & Prince, R (1991). The comor-
bidity of borderline personality disorder and other DSM-III-R Axis II personality disorders.
American Journal of Psychiatry, 148, 1371-1377.
O'Brien, M. M., Trestman, R L., & Siever, L. J. (1993). Cluster A personality disorders. In D. L. Dun-
ner (Ed.), Current psychiatric therapy (pp. 399-404). Philadelphia: Saunders.
Oldham, J. M., Skodol, A. E., Rellman, A. D., Hyler, S. E., Rosnick, L., & Davis, M. (1992). Diagnosis
of DSM-III-R personality disorders by two structured interviews: Patterns of co-morbidity.
American Journal of Psychiatry, 149,213-220.
Patrick, J. (1988). Concordance of the MCMI and the MMPI in the diagnosis ofthree DSM-III Axis I
disorders. Journal of Clinical Psychology. 44, 186--190.
Patterson, G. R (1982). Coercive family process. Eugene, OR: Castalia.
Pennington, B. H., Peterson, L. P., & Barber, H. R (1979). The diagnostic use ofthe MMPI in organic
brain dysfunction. Journal of Clinical Psychology. 35, 484-492.
Perry, J. C. (1993). Longitudinal studies of personality disorders. Journal of Personality Disorders, 7,
63-85.
Peterson, C. (1996). Personality (2nd ed.). San Diego, CA: Harcourt Brace jovanovich.
Pfohl, B.• Stangl. D., & Zimmerman, M. (1983). Structured Interview for DSM-III Personality (SIDP)
(2nd ed.). Iowa City: University ofIowa.
pfohl, B., Blum. N., & Zimmerman, M. (1995). Structured Interview for DSM-IV Personality SlDP IV.
Iowa City: University of Iowa.
Pincus, H. A.. Frances. A., Davis, W. w., First, M. B., & Widiger, T. A. (1992). DSM-IV and new di-
agnostic categories: Holding the line on proliferation. American Journal of Psychiatry, 149,
112-117.
Quality Assurance Project. (1991). Treatment outlines for paranoid, schizotypal, and schizoid per-
sonality disorders. Australian and New Zealand Journal of Psychiatry, 24, 339-350.
Reich, J. H., & Green, A. I. (1991). Effect of personality disorders on outcome of treatment. Journal
of Nervous and Mental Disease, 179, 74-82.
Renneberg, B., Goldstein, A. J., Phillips, D., & Chambless, D. L. (1990). Intensive behavioral group
treatment of avoidant personality disorder. Behavior Therapy. 21,363-377.
Ricciardi, J. N., Baer, L., Jenike, M. A .. Fischer, S. Coo Sholtz, D., & Buttolph, M. L. (1992). Changes
in DSM-III-R Axis II diagnoses following treatment of obsessive-compulsive disorder. Ameri-
can Journal of Psychiatry, 149,829-831.
Rose, M. K., Soares, H. H., & Joseph, C. (1993). Frail elderly clients with personality disorders: A
challenge for social work. Journal of Gerontological Social Work. 19, 153-165.
Rosowsky, E., & Gurian, B. (1991). Borderline personality disorder in late life. International Psy-
chogeriatrics, 3, 39-52.
Rusk, R., Hyerstay, B. J., Calsyn, D. A., & Freeman, C. W. (1979). Comparison of the utility of two ab-
breviated forms of the MMPI for psychiatric screening of the elderly. Journal of Clinical Psy-
chology, 35, 104-107.
Schneider, 1. S., Zemansky, M. F., Bender, M., & Sloane, R. B. (1992). Personality in recovered de-
pressed elderly. International Psychogeriatrics, 4, 177-185.
Schneier, F. R., Spitzer, R. 1. Gibbon, M., Fyer, A. J., & Leibowitz, M. R. (1991). The relationship of
social phobia subtypes to avoidant personality disorder. Comprehensive Psychiatry, 32,
496-502.
Segal. D. 1., Hersen, M., Van Hasselt, V. B., Silberman, C. S., & Roth, 1. (1996). Diagnosis and
assessment of personality disorders in older adults: A critical review. Journal of Personality
Disorders.
Shea, M. T., Pilkonis, P. A., Bechman, E., Collins, J. F., Elkin, I., Sotsky, S. M., & Docherty, J. P.
(1990). Personality disorders and treatment outcome in the NIMH treatment of depression:
Collaborative Research Program. American Journal of Psychiatry, 147, 711-718.
Siegel. D. J., & Small, G. W. (1986). Borderline personality disorder in the elderly: A case study.
Canadian Journal of Psychiatry. 31, 859-860.
Silberman, C. S., Roth, 1.. Segal, D. L., & Burns, W. (1997). Relationship between the Millon Clini-
cal Multiaxial Inventory-II and Collidge Axis II Inventory in chronically mentally ill older
adults: A pilot study. Journal of Clinical Psychology, 53, 559-566.
Snyder, S., Pitts, W. M., & Gustin, Q. (1983). Absence of borderline personality disorder in later
years. American Journal of Psychiatry, 140, 271-272.
Spar, J. E., & La Rue, A. (1990). Concise guide to geriatric psychiatry. Washington, DC: American
Psychiatric Press.
Steketee, G., Foa, E. B., & Grayson, J. B. (1982). Recent advances in the behavioral treatment of ob-
sessive-compulsives. Archives of General Psychiatry. 39, 1365-1371.
Stravynski, A., Lesage, A., Marcouiller, M., & Elie. R (1989). A test of the therapeutic mechanism in
social skill training with avoidant personality disorder. Journal of Nervous and Mental Dis-
ease, 177, 739-744.
Streiner, D. L. & Miller, H. R (1988). Validity ofthe MMPI scales for DSM-III personality disorders:
What are they measuring? Journal of Personality Disorders, 2, 238-242.
Task Force on Nomenclature and Statistics, American Psychiatric Association. (1976). DSM-III in
midstream: Conference publication. Missouri Institute of Psychiatry.
Taylor, J. R, Strassberg, D. S., & Thrner, C. W. (1989). Utility ofthe MMPI in geriatric populations.
Journal of Personality Assessment, 53, 665-676.
Thompson, 1. W., Gallagher, D., & Czirr. R. (1989). Personality disorder and outcome treatment of
late life depression. Journal of Geriatric Psychiatry, 21,133-146.
Thrkat, I. D., & Carlson, C. R. (1984). Data-based versus symptomatic formulation of treatment: The
case of a dependent personality. Journal of Behavior Therapy and Experimental Psychiatry,
15,153-160.
Tyrer, P. (1988). What's wrong with the DSM-III personality disorders? Journal of Personality Disor-
ders, 2, 289-291.
Weiss, J. M. (1973). The natural history of antisocial attitudes: What happens to psychopaths? Jour-
nal of Geriatric Psychology, 2, 236-242.
Westin, D. (1991). Cognitive-behavioral interventions in the psychoanalytic psychotherapy of bor-
derline personality disorders. Clinical Psychology Review, 11, 211-230.
Widiger, T. A., & Thull, T. J. (1993). Personality and psychopathology: An application of the five-fac-
tor model. Journal of Personality, 60, 363-393.
Widiger, T. A., Williams, J. B., Spitzer, R F., & Francis, A. (1985). The MCMI as a measure ofDSM
III. Journal of Personality Assessment, 49, 366-378.
Zimmerman, M. (1994). Diagnosis of personality disorders. Archives of General Psychiatry, 51,
225-244.
CHAPTER 15
Aging and Mental Retardation

ELLEN M. COTTER AND Loms D. BURGIO
INTRODUCTION
With the recent growth in the population of older adults, there has been a con-
comitant increase in the visibility of "special populations" of elders. One "spe-
cial population" consists of older adults with mental retardation and other
developmental disabilities. Although estimates of the size of this population
vary, it is expected that by the year 2025 there will be between 400,000 and
one million people over the age of 65 with developmental disabilities living in
the United States (see Anderson, 1993, for a review of other pertinent statis-
tics). It is believed that older adults with mental retardation constitute a group
with special needs beyond those of the general aged population (Newbern &
Hargett, 1992). For example, older adults with mental retardation have fewer
compensatory abilities than their nonretarded peers to adjust for age-associ-
ated declines in functioning (Jenkins, Hildreth, & Hildreth, 1993). As a result,
there has been a recent effort by researchers, health care professionals, and
other service providers to identify the pertinent characteristics and needs of
this special population. This information would help to determine whether ex-
isting services for older adults and persons with mental retardation are ade-
quate for meeting their needs.
The American Association on Mental Retardation (AAMR) put forth the
following definition of mental retardation in 1992:
Mental retardation refers to substantial limitations in present functioning. It is char-
acterized by significantly subaverage intellectual functioning, existing concurrently
with related limitations in two or more ofthe following applicable adaptive skill areas:
communication, self-care. home living, social skills, community use, self-direction,
health and safety, functional academics. leisure, and work. Mental retardation mani-
fests before age 18. (p. 1)
ELLEN M. COllER AND LOUIS D. BURGIO • Center for Aging, Division of Gerontology and Geriatric
Medicine, and Department of Psychology, University of Alabama at Birmingham, Birmingham, Ala-
bama 35294-4410.
323
324 Ellen M. Cotter and Louis D. Burgio
Mental retardation is portrayed commonly as the result of genetic or chromo-

somal anomalies, as in the case of Down syndrome. However, mental retarda-
tion can be caused by many other factors, such as environmental neglect,
consumption of lead, anoxia at birth, or brain trauma following a head injury or
serious illness. It is important to reiterate that onset of mental retardation oc-
curs during childhood; events such as head injuries are considered to cause
mental retardation only if they occur before the age of 18. Other conditions,
such as epilepsy, cerebral palsy, mental illness, or sensory impairments, may
coexist with mental retardation and may themselves change over the life span,
along with changes in other areas of functioning experienced by the aging adult
with mental retardation. In sum, persons with mental retardation constitute a
heterogeneous population at any point during the life span, and the diversity of
this population increases with age.
Until recently, individuals with mental retardation manifested a shorter life
span than the nonretarded population, although improved medical technology
has resulted in nearly equivalent life spans for both the retarded and general pop-
ulations. Because of this history of shortened life expectancy, however, there re-
mains a somewhat liberal definition regarding the age at which an adult with
mental retardation can be considered to be "elderly." Furthermore, differential
loss of function at a particular age between retarded and nonretarded older adults,
as well as variability within the group of older adults with mental retardation, ren-
der the description "elderly" problematic. The age of 65, which is one standard
marker for senior citizenship in the general population, is now commonly at-
tained by many adults with mild to moderate mental retardation. However, it has
been suggested that adults with mental retardation who are as young as 55 can be
classified as "elderly" (Eklund & Martz, 1993; M. M. Seltzer & Krauss, 1987), par-
ticularly if other conditions such as Down syndrome are present or if the person
has severe or profound mental retardation. Such lack of agreement on age stan-
dardization presents an important challenge to service providers and researchers.
It is crucial that geropsychologists be aware of the special needs of their
clients with mental retardation. Unlike other forms of psychopathology, such as
anxiety disorders and depression, mental retardation itself is not treatable, al-
though some specific aspects of mental retardation can be treated and allevi-
ated. In addition, it is important that clinicians be sensitive not only to the
age-related changes experienced by older adults with mental retardation but
also to the inherent difficulties in assessing these changes with this population.
The primary purpose of this chapter is to present a few of the more salient is-
sues clinicians may face when providing services for aging retarded individu-
als. Topics covered include diagnosis and assessment of aging-related changes,
treatment of problem areas, special issues regarding aging persons with Down
syndrome, caregiving, and service needs.
DIAGNOSIS AND ASSESSMENT

Although the diagnosis of mental retardation is generally formed in child-
hood, it is possible that the condition may be undiagnosed until adulthood due
to coexistence of other conditions, such as mental illness or a severe sensory
Aging and Mental Retardation 325
impairment. However, even with individuals who are not diagnosed until later
in life, regular assessment across the remaining life span is vital to effective ser-
vice provision. Like their nondisabled peers, individuals with mental retarda-
tion continue to change throughout their lives, and regular assessment of
abilities will ensure that needs are being met.
Because individuals with mental retardation constitute a diverse popula-
tion, it should be expected that these individuals will display characteristics of
aging variably. In particular, there appears to be a qualitative difference in the
aging process for persons with Down syndrome when compared with individ-
uals whose mental retardation was caused by other factors. Some of these dif-
ferences will be addressed in a separate section on the relationship between
Down syndrome and Alzheimer's disease. Other differences will be discussed
as needed in this section.
Cognitive Functioning
Longitudinal research investigating aging-related cognitive changes in

nondisabled adults has revealed that cognitive processes, particularly those re-
quiring speed or perceptual abilities, decline with increasing age, but that this
decline is less than was previously found in cross-sectional studies of cognitive
function. A similar pattern has been found in individuals with mental retarda-
tion. In their now classic 1970 study, Fisher and Zeaman found that adults with
mental retardation show relatively intact performance on verbal tasks through-
out their lives, with a greater decline in performance-based tasks with increased
age. Overall IQ scores were found to remain relatively stable until at least age
60. Eklund and Martz (1993), however, note that this and other studies have fo-
cused primarily on institutionalized persons and used post hoc evaluations of
archival data.
In a cross-sectional examination of adults with mental retardation (age
range 20-90 years) who did not have Down syndrome or profound mental re-
tardation, Hewitt, Fenner, and Torpy (1986) found that mental age remained
constant until around age 65, and then showed a slight decline. These findings
are consistent with the work of Bell and Zubek (1960), who found no decline in
IQ over a 5-year span in retarded adults over the age of 45 who did not have
Down syndrome, and Harper and Wadsworth (1990), who found that chrono-
logical age was not related to IQ change in adults with mental retardation rang-
ing in age from 35 to 79 years. In summary, it appears that among retarded
adults without Down syndrome, cognitive ability remains stable until roughly
age 65, after which slight and gradual declines are seen. It should be noted that
persons with Down syndrome appear to display a different pattern of cognitive
aging, and thus should be considered separately in studies of associated cogni-
tive changes. In particular, data suggest that individuals with Down syndrome
begin experiencing cognitive decline in their late 40s (e.g., Fenner, Hewitt, &
Torpy, 1987; Hewitt, Carter, & Jancar, 1985).
Accurate assessment of cognitive ability in older adults with mental retarda-
tion is essential not only for determining current levels of functioning but also for
documenting changes in cognitive ability over time. Unfortunately, selection of an
appropriate assessment tool is problematic. Different intelligence tests, such as the

Wechsler Adult Intelligence Scale-Revised (WAIS-R) and the Stanford-Binet In-
telligence Scale: Fourth Edition, have been found to produce disparate IQ scores
(Spitz, 1986). The Stanford-Binet does not have adequate standardization norms
for older adults (Spruill, 1991), and the directions for administration of the Stan-
ford-Binet may unfairly penalize examinees with mental retardation (Wersh &
Thomas, 1990). Moreover, neither the WAlS-R nor the Stanford-Binet provides ex-
plicit instructions for use with persons who have severe language, physical, or sen-
sory impairments. Proposed solutions to these problems include the use of
"hybrid" assessments containing components from more than one instrument
(e.g., Eklund & Martz, 1993) or a children's assessment battery adapted for adults
(e.g., Hogg & Moss, 1993); however, these approaches are also problematic. It is not
the purpose of this chapter to propose a particular cognitive assessment tool, but it
is recommended that clinicians familiarize themselves with these issues and exer-
cise caution when selecting or interpreting the results of an intelligence test.
Adaptive Behavior
The term "adaptive behavior" refers to a class of skills encompassing man-

agement of activities of daily living (ADLs), performance of instrumental activ-
ities of daily living (IADLs), and the ability to interact in socially appropriate
ways (AAMR, 1992). As with assessment of cognitive ability, measuring adap-
tive behavior skills in elderly adults with mental retardation is complicated by
lack of appropriate instruments. Two instruments are particularly worthy of
discussion because of their common usage. Although the Vineland Adaptive
Behavior Scale is a popular assessment tool, it has been noted that this instru-
ment contains many items geared toward children. The scale also overempha-
sizes written communication in older examinees, and it does not provide
standardization norms for older adults (Kerby, Wentworth, & Cotten, 1989).
The American Association on Mental Deficiency (AAMD) Adaptive Be-
havior Scale (Nihira, Foster, Shellhaas, & Leland, 1974), which assesses both
adaptive behavior skills and the occurrence of maladaptive behaviors, includes
appropriate norms for use with older adults. However, this instrument is diffi-
cult to score, was standardized on an institutional population, and includes a
number of biased items. For example, self-care during menstruation is rated on
a five-point scale, with a higher score denoting more independence. Male
clients, for whom menstruation is irrelevant, are automatically given five points
in scoring, regardless of their abilities in other aspects of self-care. An updated
version of this scale, the AAMR Adaptive Behavior Scale (Nihira, Leland, &
Lambert, 1993), alleviates some of these problems by eliminating some biased
items and providing norms for both institutional and community-dwelling pop-
ulations; unfortunately, this instrument is not yet widely used.
Although finding an appropriate instrument is problematic, measurement
of adaptive behavior is central to the continuing habilitation of older adults
with mental retardation. It has been noted that the client's functional ability is
an important factor in guiding the allocation of services and achieving the least
restrictive environment (Kerby et a1., 1989). In fact, when assessing the "good-
ness of fit" between elderly persons with mental retardation and their environ-
ments, adaptive skills are frequently targeted (G. B. Seltzer, Finaly, & Howell,
1988). In addition, documentation of adaptive behavior skills over time has
been proposed as a valid way to assess the life-span development of persons
with mental retardation. Longitudinal assessment of adaptive behavior skills
has revealed that functional abilities of both institutionalized and community-
dwelling adults with mild to moderate mental retardation plateau in early
adulthood and remain relatively intact through age 64 (Eyman & Widaman,
1987). However, adaptive behavior of individuals with more severe impair-
ments or levels of mental retardation flattens out in early childhood and tends
to decline in the mid-40s (Eyman & Widaman, 1987). These results again high-
light the heterogeneity of older individuals with mental retardation and suggest
that different levels of impairment must he considered when examining longi-
tudinal performance of adaptive behavior skills.
Longitudinal issues aside, the assessment of adaptive behavior skills has
relevance for determining current service needs. Using a slightly modified ver-
sion of the Katz Index of ADL (Katz, Ford, Moskowitz, Jackson, & Jaffe, 1963),
Eklund and Martz (1993) conducted a 2-year study of 128 older adults with
mental retardation, 64 of whom had Down syndrome and 87% of whom lived
with their parents or in group homes. Results indicated that older adults with
mental retardation were largely independent in terms of basic ADLs (e.g.,
bathing, dressing, and toileting) but required more assistance with IADLs (e.g.,
using money, preparing meals, traveling in the community). Eklund and Martz
(1993) also suggest that a decline in IADL performance indicates the need for
increased environmental supports, whereas a decrease in ADL independence
may suggest the need for out-of-home placement.
Fine, Tangeman, and Woodard (1990) assessed postdeinstitutionalization
changes in the adaptive functioning of older adults with mental retardation. The
32 residents in this study had lived in a state institution and had been transferred
to a smaller, neighborhood-based facility. Residents ranged in age from 40 to 78 at
the time of deinstitutionalization. In this study, deinstitutionalization was related
to increases in both adaptive and maladaptive behaviors. similar to results ob-
tained with younger samples of adults with mental retardation. Specific types of
adaptive behaviors that showed improvement were economic, language, and do-
mestic skills; the increase in maladaptive behaviors-specifically, antisocial be-
havior, untrustworthy behaviors, and unacceptable vocal habits-appeared to be
related to increased interaction with other people. These results show that older
adults with mental retardation can learn new ADL skills following a change to a
less restrictive environment. The results also suggest that alerting facility staff of
potential maladaptive behavior changes and training them in behavior manage-
ment skills might make the residential transfer smoother for both clients and staff.
Physical Health
Knowledge ofthe health status and health needs of older adults with men-
tal retardation is critical for effective service planning. It is important to deter-
mine not only how older adults with mental retardation compare to their
nonretarded peers in their experience of certain health conditions, but also

whether or not the health services currently available to older adults can
accommodate mentally retarded individuals. Variations in life history, includ-
ing such factors as institutionalization and prior health care availability, will
affect the health status and needs of older adults with mental retardation. In
addition, there is some evidence that differences in the severity of mental re-
tardation or the presence of other disabling conditions or both also produce
variability in aging-related health status and health care needs. These differ-
ences also need to be taken into account when planning services to address the
health needs of these individuals.
Assessment of physical well-being in this population can be less problem-
atic than the assessment of cognitive or functional abilities because medical
professionals use a fairly standard set of techniques to assess, diagnose, and
treat illness. Lack of appropriate age norms and poor psychometric properties
are less relevant issues. However, older adults with mental retardation may
have difficulty describing or expressing their symptoms; as a result, medical
professionals must be attuned to nonverbal expressions of pain or illness. More-
over, family members may not be available to provide medical history or su-
pervise treatment, and the frequent staff turnover in residential facilities may
result in staff members' being unaware of a resident's medical history or needs.
As they age, adults with mental retardation face the same health issues as
their nonretarded peers. For example, increased prevalence of age-related con-
ditions such as arthritis, heart disease, and sensory impairments is common to
all aging individuals. Problems related to medication use are also common in
these two groups. Alterations in body metabolism affect the absorption and ef-
fectiveness of medications, onset of age-related health problems may result in
the necessity for new medications, and lack of communication between pa-
tients and physicians may result in deleterious drug interactions. However,
older adults with mental retardation may experience some age-related medica-
tion complications unique to this population. Many individuals with mental re-
tardation take medication throughout their lives for the control of seizure
disorders, behavioral disturbances, or mental illness. Some of these medica-
tions, such as antipsychotic drugs, can produce long-lasting negative side ef-
fects, such as tardive dyskinesia, if taken over long periods of time. It is also
known that, as they age, individuals become more susceptible to the adverse
side effects of antipsychotic drugs.
To date, much of the data on the health of older adults with mental retar-
dation has been gathered through the National Nursing Home Survey (NNHS;
National Center for Health Statistics, 1979, 1986). This database contains an
abundance of information on both retarded and nonretarded nursing home
residents. Results from this database suggest that older adults with mental re-
tardation have better overall health than their nonretarded peers. More specifi-
cally, nursing home residents aged 65 and older with mental retardation
typically have a lower incidence of health problems such as arthritis, respira-
tory disorders, Parkinson's disease, and circulatory system disorders than their
nonretarded peers. However, epilepsy and other nervous system disorders are
more common in nursing home residents with mental retardation (Anderson,
1989, 1993).
A longitudinal study conducted at the University of Minnesota Center for

Residential and Community Services (CRCS; Anderson. Lakin. Bruininks. &
Hill. 1987) has also provided valuable data on the characteristics of older adults
with mental retardation residing in state-run residential facilities. including
small group homes. foster homes. and large public and private institutions. Un-
like the NNHS project. the CRCS study does not include data from nonretarded
individuals. The CRCS sample of 370 adults was studied longitudinally over a
5-year period. During this time. overall incidence of heart disease and arthritis
increased. a phenomenon not unexpected in this aging group. Paradoxically.
there was a higher incidence of reported chronic diseases and muscle atrophy
among individuals who had remained in their original residences during the
study. compared with those who were transferred to a setting offering more
functional and medical assistance. Anderson (1993) suggested that these seem-
ingly incongruous results are caused by staff underreporting of various condi-
tions. Whether this hypothesized underreporting is deliberate or accidental is
unclear. However. as previously mentioned. high staff turnover rates in resi-
dential facilities may result in a lack of information about the medical histories
and current health status of the residents. Although direct comparison of the
CRCS and NNHS data sets is problematic because of differences in the methods
of data collection. a cursory examination suggests that the overall prevalence of
medical conditions in older adults with mental retardation who live in com-
munity residential facilities is similar to that of the retarded nursing home res-
idents (Anderson. 1989. 1993).
It has been noted that diversity among older adults with mental retardation
renders it difficult to discuss in general terms the physical aging of this popu-
lation (e.g .. Anderson. 1993). In particular, individuals with different degrees of
mental retardation or other debilitating conditions or both may have different
patterns of aging. Individuals with mild to moderate mental retardation appear
to have a life expectancy similar to that of the general aging population. As
these individuals age. they also experience many of the health problems com-
mon to their age group. such as sensory losses. incontinence. and confusion. As
mentioned previously, diagnosis of these conditions can be difficult. For exam-
ple, older adults with mild to moderate mental retardation may not be able to
convey sensory losses or understand how these sensory losses affect their in-
teractions with their environment and other people. Incontinence in a retarded
individual may be viewed as a behavior problem and not as an outcome of an
underlying medical condition. Also. confusion may not be easily detectable,
particularly if the client has a history of mental illness or behavior problems
(Anderson, 1993). All of these factors can affect the accurate diagnosis and
treatment of common medical conditions in aging retarded individuals.
Greater levels of cognitive and functional impairment appear to be corre-
lated with more frequent and serious health problems. Individuals with severe
to profound mental retardation have a shortened life expectancy due to frequent
presence of other complicating medical conditions. such as respiratory diseases
(Anderson, 1993). They also have a higher incidence of non-age-related health
conditions and sensory deficits and, consequently, are severely limited in their
ability to report physical signs and symptoms. Furthermore. addition of a condi-
tion such as epilepsy or cerebral palsy to existing mental retardation, regardless
of degree of cognitive impairment, may reduce life expectancy and introduce ad-
ditional health complications (Anderson, 1993).
Finally, individuals with Down syndrome have a life expectancy of approx-
imately 55 years (Eyman, Call, & White, 1989). This life expectancy is lower than
that of other adults with mental retardation not caused by Down syndrome. Peo-
ple with Down syndrome are also more susceptible to congenital heart disease,
middle ear infections (which eventually cause a conductive hearing loss), hy-
pothyroidism, and premature aging of the immune system (Adlin, 1993). Conse-
quently, it has been suggested that individuals with Down syndrome age faster
than people without Down syndrome (Eklund & Martz, 1993); however, the
mechanism by which such premature aging occurs is still unknown.
Behavior Problems
It is estimated that between 10% and 60% of individuals with mental re-
tardation evince behavior problems (Davidson et al., 1992). Examples of these
behavior problems include physical aggression, noncompliance, running away,
and self-injurious behaviors. These maladaptive behaviors have obvious poten-
tial consequences, such as damage to property and injury to the self and oth-
ers. It is thought that maladaptive behaviors also cause difficulty in social
relationships, lessen employment opportunities, and increase the risk of insti-
tutionalization (see McGrew, Ittenbach, Bruininks, & Hill, 1991, for a review).
Indeed, behavioral disturbances are cited as a primary barrier to inclusion in
the community for individuals with mental retardation (Davidson et al., 1992).
Assessment of behavioral disorders in older adults with mental retardation
can be conducted in many ways. The most useful for establishing the an-
tecedents and consequences of maladaptive behavior is to record a behavioral
disturbance as it occurs. Graphing the occurrence of behavioral disturbances
over time can establish possible patterns of behavior, identify antecedents and
consequences, and show the effectiveness of interventions. However, direct ob-
servation of behavioral disturbances can be time-consuming for caregivers and
may not be feasible in some situations. More standardized measures of be-
havioral disturbances are also available. One section of the AAMD/ AAMR
Adaptive Behavior Scales (Nihira et al., 1974, 1993) assesses occurrence of mal-
adaptive behavior in 14 domains, including one domain that assesses use of
medications. Behaviors are rated as occurring "occasionally" (one point) or
"frequently" (two points). Point totals in different domains are then compared
to standardized norms for different age groups. Although this method of as-
sessing behavior problems is convenient and useful for comparing one client's
behavior with that of other individuals, it is not as effective in documenting be-
havior patterns or behavior change. Furthermore, this method does not always
differentiate the frequency of a behavior problem from its severity. A behavior
problem, for example, disruptive vocalization, may occur frequently but may
not be as troublesome as a less frequent problem, such as physical aggression
that results in injury.
A frequently asked question is whether behavioral disturbances in men-
tally retarded individuals change with the aging process. The answer to this
question depends on several factors. One is the accuracy of reporting the fre-
quency, duration, and severity of these behaviors. Inaccurate reporting will, of

course, result in inaccurate profiles of behavior over time. A second factor is the
presence or absence of age-related disease conditions. People who develop res-
piratory or circulatory system disorders as they age may not have the strength
to engage in behaviors such as trespass or physical aggression but may show an
increase in verbal disruption and noncompliance. In addition, an older adult
with mental retardation who develops a dementing illness may show a differ-
ent pattern of behavioral disorders than had been present earlier in life; this
change in behavior can be attributed to the dementia and not to aging per se. A
third factor is related to changes in life events. Older adults with mental retar-
dation may have difficulty adjusting to such life transitions as a change in resi-
dence, the death of a family member, or retirement from a work setting. Changes
in behavioral disorders may occur for lack of other, more appropriate, coping
mechanisms or methods of expression.
Davidson and colleagues (1992) conducted a cross-sectional study of aging
effects on behavioral and psychiatric disorders in community-dwelling adults
with mental retardation. Records of clients who had been referred for crisis inter-
vention services due to the severity of their behavior problems were examined.
With increasing age. number of referral problems increased. However, some of the
referral problems included in this sample, such as caregiver illness or death,
client abuse or neglect, and client illness, cannot be considered to be client be-
havior problems. When client behaviors such as aggression and noncompliance
were examined separately from the larger list of referral problems, occurrence of
aggression remained relatively constant with age, noncompliance increased with
age, and prevalence of psychiatric symptoms declined. When older clients with
mild and severe mental retardation were compared, different patterns of behavior
problems emerged. Clients with mild mental retardation who were at least 50
years of age showed a marked increase in noncompliance and a marked decrease
in physical aggression compared with adults with mild mental retardation who
were 40 to 49 years of age. Specifically, the percentage of each group that engaged
in aggressive behavior dropped from over 30% to zero, while the percentage of
each age group that exhibited noncompliant behaviors increased from roughly
40% to 85%. Older adults with severe mental retardation, however, showed a dif-
ferent pattern of behavior. Compared to middle-aged adults with severe mental re-
tardation, older adults showed a increase in noncompliance from none to 25%
and an increase in aggression from 40% to approximately 60%. This interaction
of "pattern of behavioral crisis" and severity of mental retardation suggests that
different methods of assessment and intervention may be necessary for older
adults with varying levels of mental retardation, although it is noted that "the role
played by psychiatric factors in determining age-dependent patterns of severe be-
havioral disturbances is unclear" (p. 1).
In a more recent study, Davidson and colleagues (1994) have reported that
in a sample of community-based adults with mental retardation (approxi-
mately 18% were aged 40 or above), aggressive behaviors did not decrease
with age, and the proportion of the sample who engaged in aggressive behav-
iors remained constant across the life span. In contrast with results reported by
McGrew and colleagues (1991). these clients did not display an increase in
self-injurious behaviors with age; however, differences in sampling procedures
and problem definition may be responsible for this discrepancy.
TREATMENT OF PROBLEM AREAS
Behavior Problems
As stated previously, behavior problems are common among individuals

with mental retardation, and many of these problems are maintained into old
age. Two common forms of treatment are the use of psychotropic medications
and behavioral interventions.
Psychotropic Medication
Use of psychotropic medications to treat behavior disorders is common, al-
though prevalence varies by residential setting. It is estimated that 30%-50% of
adults with mental retardation who live in institutions receive major tranquil-
izers on a regular basis, but only 26%-36% of community-based clients take
neuroleptic drugs (Anderson & Polister, 1993; Rinck & Calkins, 1989). Addi-
tional evidence of high use of psychotropic medications among individuals
with mental retardation can be found in J. W. Jacobson (1988) and James (1986).
The many risks associated with the use of psychotropic medications, particu-
larly among older adults, are discussed elsewhere (Butler, Burgio, & Engel,
1987; Ray, Federspiel, & Schaffner, 1980) and will not be reiterated here.
Rinck and Caikins (1989) examined psychotropic medication use among
older adults with mental retardation and found that nearly 31 % of individuals
over age 55 took at least one antipsychotic medication, compared with 23% of
adults aged 25 to 54 and 8% of persons younger than age 21. Older adults with
mental retardation were also more likely to take more than one antipsychotic
medication. Similarly, approximately 8% of adults with mental retardation
aged 75 and above took antianxiety medications, compared with approximately
4% of adults aged 25 to 54. In addition, the highest prevalence rates of antipsy-
chotic drug use were found among older residents of skilled nursing homes and
intermediate care facilities; residential setting, not occurrence of maladaptive
behavior, was the primary predictor of psychotropic drug use in adults with
mental retardation who were more than 65 years of age. Unfortunately, little is
known about effectiveness of pharmacotherapy in older adults with mental re-
tardation; however, based on data from research with nonretarded elders, there
is little compelling evidence supporting the use of pharmacotherapy for treat-
ing geriatric behavioral disturbances. A recent metanalysis concluded that only
one in five elderly patients appears to benefit from pharmacotherapy (Schnei-
der, Pollock, & Lyness, 1990).
Behavioral Interventions
Use of behavioral interventions to manage maladaptive behaviors in older
adults with mental retardation poses less risk than use of pharmacotherapy and
has been recommended for geriatric populations (Burgio & Burgio, 1986; Car-
stensen, 1988; Jencks & Clausen, 1991). Behavior therapy has been used fre-
quently to teach self-care skills to adults with mental retardation (e.g., Whitman,
Scibak, & Reid, 1983) and to control behavior disturbances in children with
mental retardation (e.g., Friman, Barnard, Altman, & Wolf, 1986). As a result, it
would appear that behavior therapy techniques, such as differential reinforce-
ment of incompatible behavior (DRI), would have utility for use with a geriatric
population of individuals with mental retardation. However, creating a useful
explanatory model to assess antecedents and consequences of some maladaptive
behaviors, such as pica, may be difficult, and the cognitive and language limita-
tions present in many persons with mental retardation will make some models
and types of treatment infeasible (Matson & Gardner, 1991). Although research
has demonstrated some utility of behavior therapy principles in treating the mal-
adaptive behaviors of adults with mental retardation (Matson & Gardner, 1991;
Peterson & Martens, 1995), older adults with mental retardation have not been
extensively examined, and thus no definitive conclusions can be drawn at this
time about the use of behavior therapy with this population.
One strategy of behavior therapy postulated to be effective in controlling be-
havior disturbances involves use of exercise to decrease maladaptive behavior.
Participating in vigorous exercise may provide a socially acceptable outlet for ag-
itated or aggressive behaviors. Furthermore, exercise or athletic activity provides
a natural setting for ignoring maladaptive behaviors (e.g., throwing a ball can be
deliberately misinterpreted as participation) and for the performance of behaviors
incompatible with aggression or self-abuse. In their review of the available litera-
ture, Gabler-Halle, Halle, and Chung (1993) found a general trend for maladaptive
behaviors in adults with mental retardation to improve following exercise; how-
ever, none of the studies reviewed included older adults among their samples. El-
liott, Dobbin, Rose, and Soper (1994) compared vigorous aerobic exercise (e.g.,
jogging on a treadmill) to less vigorous exercise (e.g., riding an exercise bike, lift-
ing light weights) and found that aerobic exercise effectively, though temporarily,
reduced stereotypic and aggressive behaviors in adults with autism and mental
retardation. While older adults were not specifically targeted, it was noted that
the three oldest adults in the sample (mean age = 35 years) displayed the most
significant reductions in maladaptive behaviors following exercise.
Mental Illness
Overview
It has been demonstrated that individuals with mental retardation have a
higher probability of developing mental illnesses during their lives. The rea-
sons for such increased risk have not been determined, although it has been hy-
pothesized that impairments in communicative and information-processing
abilities might result in a reduced ability to cope with stressful life situations
(Menolascino & Potter, 1989). As in the general population, hereditary factors
may also place the individual at increased risk for developing a mental illness.
A particularly relevant risk factor for older adults with mental retardation is
"the severe psychosocial deprivation" associated with institutional environ-
ments (Menolascino & Potter, 1989).
Foelker and Luke (1989) outlined some primary problems associated with
the detection and accurate diagnosis of mental illness in individuals of any age
with mental retardation. Because the primary duty of psychologists working in

mental retardation settings is to assess cognitive and adaptive behavior skills,
occurrence of mental illness in a client may be overlooked. Individuals with
mental retardation may be unable to label or interpret their feelings and also
may not know how to ask others for help in managing their feelings. Existing
patterns of behavior may mask symptoms of a mental illness, particularly if the
individual commonly exhibits maladaptive behaviors. In addition, symptoms
of a mental illness may be interpreted by caregivers as a behavior problem that
is related to environmental factors (Alford & Locke, 1984). The high staff
turnover at residential facilities may result in a lack of information about
clients' behavior patterns and mental health history. Finally, many psychomet-
ric tests used to diagnose psychopathology are written at the eighth-grade level
and may not be understood by adults with mental retardation; moreover, the
normative data for these instruments are not based on data from persons with
mental retardation.
7ypes of Mental Illness

Depression. As recently as the 1970s, it was believed that people with
mental retardation did not have the cognitive abilities necessary to experience
depression (Winokur, 1974). This view is no longer widely held, although it is
believed that the diagnosis of depression in individuals with mental retardation
can include somewhat "nontraditional" depressive symptoms such as self-
injury and aggression. However, self-reported feelings of depression and "tradi-
tional" signs of depression such as sad affect or withdrawal should also be con-
sidered when forming a depression diagnosis in these individuals (see Harper
& Wadsworth, 1990).
Because of the types of life transitions common to aging retarded individu-
als, they are thought to have a high risk of developing depression. For example,
older adults with mental retardation may experience depression following per-
sonallosses such as the death of a family member or friend, loss of a job due to
retirement, or residential transitions due to declining health. Harper and
Wadsworth (1990) investigated occurrence of depression in adults with moder-
ate mental retardation who were at least 45 years of age. In this sample, there
was a positive relationship between age and depression as measured by the
Hamilton Rating Scale for Depression. However, occurrence of life events that
may have produced depression was not examined. In a later study, Harper and
Wadsworth (1993) examined the experience of grief in adults with mental re-
tardation (including subjects in their 70s) and determined that the types of grief
reactions (e.g., sadness, confusion, and anger) experienced by adults with mod-
erate to severe mental retardation were similar to those experienced by nonre-
tarded adults; however, differences in the manner in which these reactions
were expressed and the intensity of the reactions were less clear.
Dementia. Dementia is a global term applied to a group of disorders char-

acter by progressive decline in cognitive and functional abilities. Dementias of
certain etiologies, such as dementia caused by adverse drug interactions, are po-
tentially reversible. However, as in the case of Alzheimer's disease, most de-
mentias are irreversible. It is thought that adults with mental retardation are
particularly susceptible to developing dementia as they age because of neuro-
logical vulnerability and the interaction of organic and psychiatric disease
(Harper & Wadsworth, 1990). (Older adults with Down syndrome appear to be
especially vulnerable to this condition; this phenomenon will be discussed
later in this chapter.) A diagnosis of dementia is properly made following ex-
tensive medical and cognitive evaluations to rule out other causes of impair-
ment. Memory loss is generally the first noticeable feature of dementia, but
other symptoms (such as behavior changes, decline in ADLs, or loss of social
skills) may also indicate the onset of a dementing illness.
Misdiagnosis of dementia can occur when a physical ailment or mental ill-
ness causes confusion, behavioral changes, or functional decline in a client.
Older adults with mental retardation are particularly at risk for misdiagnosis of
dementia because of the poor communicative skills of this group. The confu-
sion or behavioral changes that can result from poor nutrition or that accom-
pany physical ailments such as infections or endocrine disorders may resemble
dementia and could be diagnosed as such if not differentially diagnosed by the
clinician. One example is the case of delirium, a cognitive disorder character-
ized by a disturbance of attentive function and a decline in cognitive abilities
which is frequently misdiagnosed as dementia. Delirium generally develops
over a short period of time and is caused by a medical condition (e.g., head
trauma or infections). Substance abuse, exposure to toxins, and medication side
effects are also potential causes of delirium. If properly treated, delirium is usu-
ally reversible. However, misdiagnosis can result in unnecessary treatment for
the supposed dementia and an absence of treatment for the underlying medical
condition, which may worsen and could be fatal. Mental illnesses, particularly
depression, sometimes manifest themselves as dementia-like symptoms in
older adults (Adlin, 1993); this phenomenon is often referred to as "pseudo de-
mentia." The misdiagnosis of dementia can result in unnecessary nursing home
placement and further deterioration of skills (Benson & Gambert, 1984). There-
fore, careful evaluation and consideration of symptoms are necessary to avoid
misdiagnosis.
With regard to the accurate assessment of dementia in older adults with
mental retardation, Harper and Wadsworth (1990) state that variable coopera-
tion, limitations in cognitive ability, and diminished senses and responsiveness
resulting from old age and medication use complicate such an assessment. Lack
of client education may also present assessment problems, as some dementia
screening tools require reading, writing, or performing math calculations. Neu-
ropsychologists or other professionals administering these tests may not be
aware of these special considerations. Therefore, it is difficult to determine
whether a low score on a dementia screening instrument actually reflects the
presence of dementia or is merely the result of an educationally biased assess-
ment tool, an undertrained evaluator, the limitations imposed by mental retar-
dation, or some combination of these factors. Harper and Wadsworth (1990)
advocate the use of multiple assessments to overcome these potential problems;
however, neuropsychological batteries require a substantial length of time to
administer, and the cognitive limitations of older adults with mental retarda-
tion would almost certainly require that testing be completed over several days.
It has been suggested that, at the very least, frequent ADL evaluations should be
the minimum nonmedical evaluations performed to assess changes in skill
level in older adults with severe or profound mental retardation (Janicki, Heller,
Seltzer, & Hogg, 1995).
Other Mental Dlnesses

Other forms of mental illness have been reported in older adults with men-
tal retardation. Schizophrenia, bipolar affective disorder, brief reactive psy-
chosis, personality disorders, anxiety disorders, and phobias have been
documented in clinical and research literature (Foelker & Luke, 1989; Menolas-
cino & Potter, 1989). The problems associated with the diagnosis of these con-
ditions are similar to those associated with the diagnosis of dementia and
depression. However, the more chronic psychological disorders (e.g., schizo-
phrenia) may be harder to diagnose than disorders with a more sudden onset
(e.g., brief reactive psychosis) because staff or clinicians are habituated to the
client's symptoms. Mental illnesses that have delusions or hallucinations as
part of their defining symptoms can present particular problems for individuals
with communication difficulties, due to their inability to report these symp-
toms. Failure to diagnose a mental illness accurately can not only worsen the
severity of an existing problem but also perpetuate the onset of additional dis-
orders. For example, phobias or anxiety disorders may impair the individual's
ability to establish relationships or be integrated into the community, thereby
leading to social isolation and perhaps the occurrence of more problems.
1reatment
Treatment of mental illness in older adults with mental retardation fre-
quently takes the form of pharmacotherapy. Theoretically, the primary reason
for using medications is to reduce behavioral symptoms to a manageable level,
at which time another therapeutic activity can be used (Menolascino & Potter,
1989). However, too often medication becomes the sole treatment, and the
client is placed in a "chemical restraint" with potentially harmful side effects.
In addition, using only pharmacological methods to treat mental illness does
not permit the older adult with mental retardation to learn coping strategies or
other, more effective means of dealing with his or her emotions.
Therapeutic practices such as psychotherapy or cognitive-behavioral ther-
apy, although practiced commonly with nonretarded individuals, are rarely
used as first-line treatments for mental illness in older adults with mental re-
tardation. It may be assumed that mental illness is a normal part of aging in
mentally retarded individuals, or that older adults with mental retardation will
not benefit from psychotherapy; however, preliminary research has suggested
that both of these beliefs may be inaccurate (see Foelker & Luke, 1989, for a
more detailed review). In-service training for mental retardation professionals
and paraprofessionals, as well as greater communication among the mental
health and mental retardation service delivery systems, is needed to provide
more information about the use of nonpharmacological methods of treating
mental illness in older adults with mental retardation.
The treatment of dementia in older adults with mental retardation requires

considerations different from the treatment of other types of psychological dis-
orders. As dementia progresses, the treatment of coexisting medical disorders
and mental illnesses intensifies, and new conditions develop which may also
require treatment. When a diagnosis of dementia has been established, care-
givers require education regarding the behavioral and cognitive changes that are
likely to occur. If the client has the cognitive ability to understand his or her
condition, he or she should also be told of the changes to come. Environmental
supports that maximize familiarity and safety are crucial for maintenance of
skills and prevention of behavior problems and accidents. With increasing cog-
nitive deterioration, decisions regarding nursing home placement, guardian-
ships, and advance directives become necessary. Family caregivers, residential
staff, and clinicians must be trained to recognize the symptoms of dementia and
to develop strategies to manage these symptoms in older adults with mental re-
tardation (Janicki et a1., 1995).
Impairment in Physical or Motor Ability
Functional ability, commonly defined as the ability to perform ADLs, is es-

sential to adequate quality of life and independent functioning. Functional abil-
ity is related to motor ability, for loss of motor ability impacts the performance
of ADLs. Adults with mental retardation are thought to be particularly at risk
for age-related declines in motor function (Pitetti & Campbell, 1991), not only
because they may have preexisting physical limitations, but also because they
tend to exercise less than nonretarded adults. One reason for this lack of exer-
cise is that instructional programming provided to adults with mental retarda-
tion typically does not include exercise or physical fitness except for specific
rehabilitative goals. A second reason is that older adults with mental retarda-
tion are likely to live in restrictive settings, which provide few opportunities for
exercise. Third, older adults with mental retardation may be unable to compre-
hend or appreciate the long-term benefits of exercise, particularly when the
short-term consequences can be aversive (Moon & Renzaglia, 1982; Neef, Bill-
Harvey, Shade, Iezzi, & DeLorenzo, 1995).
The exercise participation of these individuals is particularly relevant in
light of evidence indicating that adults with mental retardation are more likely to
manifest problems in cardiovascular function, obesity, and muscular strength and
endurance (see Fernhall, 1993). These three health aspects can greatly impact the
physical and functional abilities of individuals with mental retardation (Shepard,
1987) and are particularly likely to worsen with age. Studies examining the ef-
fects of training on these areas have shown mixed results. Providing training in
muscular strength and endurance does improve performance on activities such as
sit-ups and pull-ups; however, improvement on clinical measures such as isoki-
netic tests has not yet been investigated. Similarly, cardiovascular function (mea-
sured by maximal oxygen uptakes) has been found to improve with training.
However, effects of physical training on body composition (specifically, percent-
age of body fat) are still unknown (Fernhall, 1993); furthermore, information spe-
cific to older adults with mental retardation is lacking.
Because of the various factors working against older adults with mental re-
tardation in their exercise participation, and because intact physical function-
ing is so critical for maintaining independence, improving the exercise
participation of older adults with mental retardation is an important goal. Sev-
eral approaches have shown promise. Neef and colleagues (1995) used video-
taped self-modeling of a therapeutic exercise routine to improve the gait and
balance of elderly women with mental retardation. In addition to producing in-
creases in the independent exercise participation of these subjects, this inter-
vention appeared to improve the women's ability to perform a balance board
walk test. Use of a system of fading prompts, similar to that used to teach voca-
tional and self-care skills, has been effective with nonretarded individuals (see
Moon & Renzaglia, 1982, for a partial review), and it could be extended to prac-
tice with older adults with mental retardation. Finally, although not yet tested
with exercise, external aids such as picture cards or computer-provided cues
have been found to improve independent activity engagement in adults with
mental retardation (Lancioni, Brouwer, Bouter, & Coninx, 1993).
Down Syndrome and Alzheimer's Disease

The high prevalence of Alzheimer's disease among older adults with Down
syndrome is well documented and has even led to the suggestion that the con-
dition of Trisomy 21 Down syndrome constitutes a risk factor for the develop-
ment of Alzheimer's disease (Dalton & Crapper-McLachlan, 1986). Autopsy
studies have demonstrated that nearly 100% of individuals with Down syn-
drome who live past the age of 40 years have the cerebral neurofibrillary tangles
and neurotic plaques that are the defining features of Alzheimer's disease. How-
ever, it is estimated that only 40% of adults with Down syndrome over age 55
have the memory loss and behavioral symptoms characteristic of Alzheimer's
disease. Why some individuals with Down syndrome fail to develop the external
manifestations of Alzheimer's disease even though their brains show the neu-
ropathological features of the disease is still unclear, although this discrepancy
does suggest the role of environmental or polygenetic factors in the expression of
Alzheimer's disease (Adlin, 1993; Dalton & Crapper-McLachlan, 1986).
Why might individuals with Down syndrome be at increased risk for
developing Alzheimer's disease? Because the likelihood of developing Alz-
heimer's disease increases with age, it is argued that Alzheimer's disease is an
age-related health condition. Individuals with Down syndrome also develop
other age-related health conditions, such as sensory impairments and osteo-
porosis, earlier in life than individuals without Down syndrome; thus, it has
been suggested that Down syndrome represents a condition of premature aging
(see Dalton, Seltzer, Adlin, & Wisniewski, 1993). Consequently, these individu-
als are predisposed to developing age-related diseases. This hypothesis would
also account for the data indicating that adults with Down syndrome develop
Alzheimer's disease at an earlier age and experience a more rapid progression
of symptoms than do adults without Down syndrome (Adlin, 1993). Many pro-
fessionals hypothesize that there is a genetic link between Alzheimer's disease
and Down syndrome. It has been reported that specific markers located on chro-
mosome 21 are linked to the gene coding for beta amyloid precursor protein,
which is thought to be involved in Alzheimer's disease neuropathology (e.g.,
Robakis et 01., 1987). Because chromosome 21 occurs in triplicate in individu-
als with Down syndrome, it is likely that individuals with Down syndrome are
at increased risk for developing this neuropathology.
Difficulties associated with assessing Alzheimer's disease in the general
population of older adults with mental retardation also apply to older adults
with Down syndrome. Lack of appropriate assessment instruments (Dalton,
1992; Dalton & Wisniewski, 1990), problems imposed by limited intellectual
and communicative abilities (Janicki et 01., 1995), and association of mental re-
tardation with impaired physical development and limited opportunities for
social development (Dalton et 01., 1993) all complicate the diagnosis of Alz-
heimer's disease in older adults with Down syndrome. These difficulties are
compounded by the possibility that older adults with Down syndrome may ex-
hibit a pattern of symptoms different from that of older adults whose mental re-
tardation is not caused by Down syndrome. Memory loss is almost always the
first symptom of dementia noted among older adults with mild to moderate
mental retardation not caused by Down syndrome. However, in the early stages
of Alzheimer's disease in older retarded adults with Down syndrome, symp-
toms such as personality changes, decline in ADLs, incontinence, and seizures
are most commonly noted (Dalton & Crapper-McLachlan, 1986; McVicker,
Shanks, & McClelland, 1994). These deviations highlight the need for thorough
diagnostic procedures to determine the presence of Alzheimer's disease in in-
dividuals with Down syndrome.
CAREGIVING
The study of issues surrounding caregiving in older adults with mental re-
tardation has received increasing attention in recent years. One reason for this
recent attention is that the increased life expectancy of adults with mental re-
tardation has prolonged the length of time that care must be provided to this
population. Family caregivers provide care to their adult children with mental
retardation during much of their lives. Although the probability of out-of-home
residential placement increases with age (Meyers, Borthwick, & Eyman, 1985),
it is estimated that 85% of individuals with mental retardation live with their
families through adulthood (Fujiura & Braddock, 1992). Transition to an insti-
tutional setting or group home generally occurs following caregiver death or in-
capacitation, although factors such as the frequency of behavior problems and
the severity of retardation are also highly associated with out-of-home place-
ment (Blacher, Haneman, & Rousey, 1992; M. M. Seltzer & Krauss, 1984).
The bulk of caregiver research has focused on the caregivers of dementia
patients. At this time, very little is known about the care or the caregivers of
older adults with mental retardation. However, there is an increasing tendency
in caregiving research to examine the caregiving relationship from a family sys-
tems perspective instead of focusing on one particular caregiver (e.g., M. M.
Seltzer & Krauss, 1994; Smith, Fullmer, & Tobin, 1994). Thus, this section will
review the research on so-called older families that include a co-residing adult
with mental retardation. In keeping with the terminology used in the research
literature, a co-residing adult with mental retardation will frequently be re-
ferred to as a "child," with the word "child" denoting the existence of a living
parent (see M. M. Seltzer & Krauss, 1994) and not implying any perceptions of
care receiver ability.
Older family caregivers of adults with mental retardation differ from other
groups of family caregivers in several ways. First, providing direct care to an
adult child is not generally perceived as a normative parental responsibility,
whereas providing direct care to young children is seen as normative. Second,
the caregiving responsibilities of parents of adult children with mental retarda-
tion tend to be lifelong in duration, whereas those families who care for non-
retarded elders generally provide this care for a much shorter period of time
(M. M. Seltzer & Krauss, 1989). Third, mental retardation is a chronic condition
that manifests itself during childhood and is marked by relative stability of
functioning over time, whereas other dependent conditions (e.g., mental ill-
ness) are characterized by a later age of onset and! or a more insidious decline in
functioning (e.g., dementia). All of these factors are thOUght to affect the man-
ner in which caregivers of adults with mental retardation cope with the de-
mands of the caregiving situation.
Research examining characteristics of older families caring for adult chil-
dren with mental retardation suggests that the heterogeneity of this population
may lead to different degrees and sources of stressors for different groups of
caregivers. For example, M. M. Seltzer, Krauss, and Tsunematsu (1993) com-
pared the caregiving relationships in families whose adult children with men-
tal retardation either had Down syndrome or did not have Down syndrome and
found that aging mothers of adults with Down syndrome reported less caregiv-
ing stress and burden, less conflicted family environments, and more satisfac-
tion with social supports than did mothers whose adult children's mental
retardation had other causes. These results complement the findings of research
conducted with families of young children with Down syndrome and mental
retardation with other etiologies (e.g., Mink, Nihira, & Meyers, 1983). M. M.
Seltzer and colleagues (1993) suggested that elderly caregivers' differences in
reported stress and social supports may result from differential social expecta-
tions (not specified) placed on the two groups of adults with mental retardation.
Alternatively, because people with Down syndrome are frequently thought to
have "easier" temperaments, it is possible that group differences in tempera-
ment and!or behavior may influence caregiver stress. Another possibility is that
the more definitive diagnosis of Down syndrome may give these two groups of
caregivers different perspectives on their caregiving. Down syndrome is usually
diagnosed at birth, whereas mental retardation of unknown etiology may not be
diagnosed for several years, and then only after a great deal of parental frustra-
tion and uncertainty. Furthermore, more is known about the developmental tra-
jectory of Down syndrome than of other types of mental retardation. Finally,
parental support groups for families of children with Down syndrome are more
common than support groups for families of children with other types of men-
tal retardation (see M. M. Seltzer et a1., 1993). These factors may give parents
of individuals with Down syndrome an "advantage" in terms of more pre-
dictability and social support.
Research examining older families caring for adults with mental retarda-
tion has frequently used as a comparison group families caring for adults with
chronic mental illnesses. Greenberg, Seltzer, and Greenley (1993) found that ag-
ing mothers of adults with mental illness reported higher levels of subjective
burden and poorer care giving relationships than did aging mothers of adults
with mental retardation. In addition, the maternal caregivers of adults with
mental retardation had larger and more cohesive support networks, faced a
smaller range of behavior problems in their adult children and, because the
adults with mental retardation were more likely to attend job or day programs,
received more respite during the day. Reporting of relatively low caregiver bur-
den among caregivers of adults with mental retardation is a common thread
throughout this research. It has been found that caregivers of adults with men-
tal retardation report lower levels of caregiving-related burden than have been
reported by caregivers of adults with mental illness (e.g., Greenberg et al., 1993)
and dementia (Zarit, Reever, & Bach-Peterson, 1980; Zarit, Todd, & Zarit, 1986),
although to date no direct comparisons have been made between dementia and
mental retardation caregiving relationships. Although the mothers of adults
with mental retardation experienced more stress associated with providing
more ADL assistance, this area was the only source of stress in which the moth-
ers of the adults with mental retardation experienced more stress than did the
mothers of adults with mental illness. Low levels of burden have been reported
in both rural and urban caregivers of adults with mental retardation, including
a recent survey conducted with Alabama caregivers (Baumhover, Gillum,
LaGory, Burgio, & Beall, 1995). It is possible that this lower burden arises from
the relative stability of a caregiving relationship involving mental retardation
compared to the fluctuation and uncertainty found in a relationship where the
care receiver has a dementing or psychiatric illness.
In a study with similar populations, M. M. Seltzer, Greenberg, and Krauss
(1995) found that mothers of adults with mental illness used more "emotion-
focused" coping strategies-considered to be less adaptive than "problem-
focused" coping strategies-than did aging mothers of adults with mental retar-
dation. Moreover, these between-group differences in use of emotion-focused
coping strategies were accounted for by between-group differences in sources
and amounts of caregiving-related stressors. As in the Greenberg and colleagues
(1993) study, mothers of the adults with mental retardation reported providing
more ADL assistance, whereas the mothers of the adults with mental illness re-
ported a higher frequency of care receiver behavior problems. However, multiple
regression analyses showed that providing more ADL assistance was a signifi-
cant predictor of stress only in the caregivers of adults with mental illnesses,
while higher frequency of behavior problems was a significant predictor of stress
among the caregivers of adults with mental retardation. M. M. Seltzer and col-
leagues (1995) hypothesized that, although mothers of adults with mental retar-
dation provide more ADL assistance than mothers of adults with mental illness,
they may see it as a normative part oftheir caregiving duties, whereas mothers of
adults with mental illness may regard ADL assistance as an unanticipated duty.
Conversely, mothers of adults with mental illness may perceive behavior prob-
lems as being normative aspects of the caregiving relationship, even though
these behavior problems may themselves be unpredictable, whereas mothers of
adults with mental retardation may regard behavior problems as being incon-
gruous with their adult children's condition.
In general, results of caregiving research highlight the importance of stabil-
ity and predictability in determining caregiver well-being. As the mental and
physical health of the caregiver ultimately impacts the care receiver, it is vital
that these factors be carefully considered in the design and implementation of
interventions for the management of caregiving-related stress and burden. In
addition, attention must be paid to factors associated with the aging of the care-
givers, as well as the aging of the care receiver. The aging caregivers of adults
with mental retardation may require increased amounts of assistance and sup-
ports that are independent of their needs as caregivers. Finally, the heterogene-
ity of caregivers of adults with mental retardation, as well as variability among
adults with mental retardation, must be taken into account when designing in-
terventions to alleviate caregiver stress.
SERVICE DELIVERY ISSUES
Because individuals with mental retardation have traditionally died at

younger ages than their nonretarded peers, developmental disabilities service
systems until recently have paid little attention to the needs of older adults
with mental retardation. However. it is now acknowledged that service delivery
systems cannot meet the needs of this population without adequate prepara-
tion. The extent to which both aging and developmental disabilities service net-
works can provide for this population is considered to be of vital importance in
determining the trajectory of service provision over the life span. In addition,
the possibility of increased "cross-training"-Le., interdisciplinary training and
sharing of knowledge between the aging and developmental disabilities service
systems (Kultgen & Rominger, 1993)-has recently been investigated as a means
of providing more comprehensive and coordinated care to older adults with
mental retardation. Studies of the service utilization patterns of older adults
with mental retardation have revealed a trend toward continuation of existing
developmental disabilities services into old age (Lakin, Anderson, Hill, Bru-
ininks, & Wright, 1991) and a strong presence of older adults with mental retar-
dation among the aging network services (M. M. Seltzer, Krauss, Litchfield, &
Modlish, 1989). However, a 1988 study of service utilization patterns in Massa-
chusetts noted that only about 5% of the services received by older adults with
mental retardation in this state were age-specialized mental retardation services
(M. M. Seltzer, 1988), suggesting that the aging and developmental disabilities
service systems may currently be running in parallel rather than in tandem.
The difficulty in planning services for older adults with mental retardation,
and the lack of widespread training in this area, may arise in part from philo-
sophical differences between the aging and developmental disabilities service
networks. In a 1992 survey of perceived "critical issues" and training needs,
31 % of the aging and developmental disabilities "experts" expressed confusion
regarding the application of treatment principles across the life span of this
client popUlation due to their differences in foci of treatment. The primary dif-
ference between the two service systems was perceived as a focus on skill
building in the developmental disabilities services versus a focus on skill main-

tenance in the aging services. Of special concern was how to reconcile these dif-
ferent perspectives and plan appropriate services for these clients. Another
relevant topic was whether the principle of active treatment could continue to
be applied when clients with developmental disabilities reached old age (Gib-
son, Rabkin, & Munson, 1992).
Residential Services
The issue of treatment needs will have a profound impact on the residen-
tial options available to older adults with mental retardation. Medicaid-funded
Intermediate Care Facilities for People with Mental Retardation (ICFs/MR),
which provide a full-time habilitative treatment program, may not be wholly
appropriate for older adults with declining health or functional abilities. Older
clients with mental retardation may have difficulty maintaining participation in
a rigorous schedule of active treatment. These declines in participation will
then almost certainly result in lack of progress in treatment, which could cause
the loss of Medicaid eligibility. Furthermore, one can question whether many of
the self-care skills that are taught in rCF/MR programs are appropriate for older
adults with mental retardation. These clients may instead require programming
to help them regain or maintain, rather than acquire, self-care skills (Redjali &
Radick, 1988). For example, a 70-year-old man who has participated in shoe-
tying and time-telling programs may better spend his time on other activities,
such as learning new leisure skills. Although one strategy for reaching these
goals would be to move the older client with mental retardation to another type
of facility, doing so may seriously disrupt the social supports available to that
client (S. Jacobson & Kropf, 1993).
Another option involves modifying the existing facility to accommodate
these new needs. Converting a residential facility to a level of care more com-
patible with geriatric needs, such as an rCF/General, requires consideration of
multiple factors. The physical plant, staff composition, activities program, and
records systems of the existing facility may all need modification to conform to
federal Medicaid guidelines (Redjali & Radick, 1988). These modifications may
be minor, as will probably be the case when changing from an rCF/MR to an
rCF/General, but may be more substantial if the starting point is a somewhat
less structured setting such as a foster care home.
When considering residential treatment options for older adults with men-
tal retardation, it is important to consider the service objectives of a residential
setting. Service professionals have stated that enhancing client independence,
improving clients' daily functioning, and delaying or preventing institutional-
ization are considered to be among the most important service objectives
(Coogle, Ansello, Wood, & Cotter, 1995). The social integration ofretarded older
adults, or the degree to which these individuals interact with nondisabled peers
through participation in leisure activities, neighborhood relationships, and com-
munity services, has also been investigated. Not surprisingly, residents of more
restrictive residential settings tend to be less integrated, as are residents with in-
creased age and more severe levels of impairment. When resident characteristics
such as age and level of impairment are controlled, the differences between res-
idential facilities remain (Anderson, Lakin, Hill, & Chen, 1992), suggesting that
the nature of the facility, rather than the age of its residents, is the most salient
factor in determining social integration opportunities. However, because older
adults with mental retardation are more likely to live in restrictive settings, fur-
ther investigation of the opportunities available to the residents of these facili-
ties, and the quality of life provided therein, is warranted.
Retirement
The issues of retirement and the options available after retirement are
somewhat problematic when older adults with mental retardation are involved.
Retirement is a life change that can affect social relationships, self-concept, and
income; older adults with mental retardation are not immune to these changes.
Adults with mental retardation may have their primary social contacts through
their jobs and may have difficulty adjusting to the loss of this network of
friends. A nonretarded retiree typically has other social roles, such as grandfa-
ther, caregiver, or wife, that compensate for the loss of the work role. An older
adult with mental retardation may not be able to fall back on such roles to es-
tablish or maintain a self-concept and thus may experience even more keenly
the loss of the worker role. Financial issues may also pose a problem. An adult
who receives Supplemental Security Income (SSI) due to lifelong disability fre-
quently uses this money to cover the cost of room and board at his or her place
of residence; money received from working is generally the only money the
client has to spend on incidentals. The loss of this income upon retirement is
rarely replaced by a pension, nor do SSI benefits increase. As a result, the re-
tiree with mental retardation may suddenly be unable to participate in activities
such as outings that require the use of "discretionary monies." This, in turn, can
result in social isolation and feelings of devaluation (Janicki, 1994).
Following retirement, there may be few activities options available to older
adults with mental retardation. This client population may not have the knowl-
edge of community services necessary for initiating meaningful postretirement
activities and may not have considered previously how they would like to
spend their retirement years. Moreover, it can be difficult for these individuals
to maintain useful vocational and adaptive skills after retirement. Therapeutic
recreation programming, including art-and-craft-related endeavors, has been
suggested as a means of providing purposeful yet entertaining activities to older
adults with mental retardation. These types of activities (e.g., tossing horse-
shoes, painting) are frequently flexible enough that all clients can participate
at some level with some degree of prompting. Through careful task analysis and
documentation of client participation and enjoyment, older adults with mental
retardation can explore new outlets of self-expression, learn new skills and
maintain old ones, and establish contacts with peers who have similar interests
(Carter & Foret, 1990; Edelson, 1990).
Activities involving integration of older adults with mental retardation into
the nondisabled elder community can widen the available network of services.
The principle of normalization (Wolfensberger, 1972) suggests that older adults
with mental retardation should have access to the same services as their nonre-
tarded, same-age peers, and that the presence of a disability should not be the
sole criterion for withholding opportunities from older adults (Wilhite, Keller,
& Nicholson, 1990). However, senior citizens' activities may be too complex
(e.g., book discussion groups) or understimulating (e.g., "activities" in adult day
care centers). Furthermore, the clients and staff in senior citizens' programs
may not be familiar with the special needs of older adults with mental retarda-
tion, potentially resulting in inadequate supervision of and discrimination
against these clients (Janicki, 1994). Adequate staff training, as well as client
education, will help ensure that older adults with mental retardation move
smoothly into integrated services.
SUMMARY
Although the increased population of older adults with mental retardation

has not remained unnoticed by researchers and service providers, relatively lit-
tle is known about their needs, and even less is known about how best to meet
these needs. Collaboration of academic researchers and direct care providers is
crucial for achieving goals related to the care of the older adult with mental re-
tardation. More information is needed on nearly every aspect of aging and men-
tal retardation. At the most basic level, the area requires a clearer and more
standardized definition of what constitutes "old" for the general population and
various subpopulations of adults with mental retardation. Research is needed on
individual and group differences in cognitive ability, adaptive behavior skills,
physical health status, maladaptive behavior, psychological disturbances, and
service needs of individuals with mental retardation over the life span. Increased
knowledge regarding the accurate diagnosis of mental illness and dementia, the
effectiveness of pharmacological and behavioral treatments for psychological
and behavioral disorders, and the remediation of functional and physical losses
is of paramount importance in determining the quality of life for older individ-
uals with mental retardation. Further investigation of the possible connections
between Down syndrome and Alzheimer's disease has the potential of providing
valuable information on the prevention of Alzheimer's disease not only among
individuals with Down syndrome but also in the population at large. Finally, the
opportunities for cooperation between the aging and developmental disabilities
service networks, and the extent to which client needs can best be met through
the collaboration of these networks, remain largely unexplored. Unfortunately,
the growth of our knowledge base has not kept pace with the growth of this pop-
ulation. We can only hope that this trend will reverse in time to avert a crisis of
care that, at this point, appears inevitable.
REFERENCES
Adlin, M. (1993). Health care issues. In E. Sutton, A. R. Factor, B. A. Hawkins, T. Heller, & G. B.
Seltzer (Eds.), Older adults with developmental disabilities: Optimizing choice and change
(pp. 49-60). Baltimore: Brookes.
Alford. J. D.• & Locke. B. J. (1984). Clinical responses to psychopathology of mentally retarded per-
sons. American Journal of Mental Deficiency. 89. 195-197.
American Association on Mental Retardation. (1992). Mental retardation: Definition. classification,
and systems of supports (9th ed.). Washington. DC: Author.
Anderson. D. J. (1989). Healthy and institutionalized: Health and related conditions among older
persons with developmental disabilities. Journal of Applied Gerontology. 8, 228-241.
Anderson. D. J. (1993). Health issues. In E. Sutton. A. R. Factor. B. A. Hawkins. T. Heller. & G. B.
Seltzer (Eds.). Older adults with developmental disabilities: Optimizing choice and change
(pp. 29-48). Baltimore: Brookes.
Anderson. D. J.• & Polister. B. (1993). Psychotropic medication use among older adults with mental
retardation. In E. Sutton. A. R. Factor. B. A. Hawkins, T. Heller. & G. B. Seltzer (Eds.). Older
adults with developmental disabilities: Optimizing choice and change (pp. 61-75). Baltimore:
Brookes.
Anderson. D. J.• Lakin. K. C.• Bruininks. R. H.• & Hill, B. K. (1987). A national study o/residential
and support services for elderly persons with mental retardation. Minneapolis: University of
Minnesota Press.
Anderson. D. J., Lakin. K. C., Hill, B. K., & Chen, T.-H. (1992). Social integration of older persons
with mental retardation in residential facilities. American Journal on Mental Retardation, 96,
488-501.
Baumhover, L. A., Gillum, J. L., LaGory. M., Burgio. L.• & Beall, S. C. (1995). A statewide study to de-
termine the status and needs of elderly types with developmental disabilities. (Report avail-
able from the Alabama Developmental Disabilities Planning Council, RSA Union Building,
100 North Union Street, P.O. Box 301410, Montgomery. AL 36130-1410.)
Bell, A.• & Zubek. J. (1960). The effect of age on the intellectual performance of mental defectives.
Journals of Gerontology, 15,285-295.
Benson. D., & Gambert. S. (1984). The impact of misdiagnosis on nursing home placement. Psychi-
atric Medicine, 1, 309-315.
Blacher, J. B., Hanneman, R. A.• & Rousey. A. B. (1992). Out-of-home placement of children with se-
vere handicaps: A comparison of approaches. American Journal on Mental Retardation, 96,
607-616.
Burgio. L. D., & Burgio, K. L. (1986). Behavioral gerontology: Application of behavioral methods to
the problems of older adults. Journal of Applied Behavior Analysis, 321-328.
Butler. F.• Burgio, L.• & Engel, B. (1987). A behavioral analysis of geriatric nursing home patients re-
ceiving neuroleptic medication: A comparative study. Journal of Gerontological Nursing, 13,
15-19.
Carstensen. L. L. (1988). The emerging field of behavioral gerontology. Behavior Therapy, 19,
259-281.
Carter, M. J.• & Foret, C. (1990). Therapeutic recreation programming for older adults with develop-
mental disabilities. Activities, Adaptation {7 Aging, 15,35-51.
Coogle, C. L.• Ansello, E. F.• Wood. J. B.• & Cotter. J. J. (1995). Partners II-Serving older persons with
developmental disabilities: Obstacles and inducements to collaboration among agencies. Jour-
nal of Applied Gerontology, 14, 275-288.
Dalton. A. J. (1992). Dementia in Down syndrome: Methods of evaluation. In L. Nadel & C. J. Epstein
(Eds.), Down syndrome and Alzheimer disease (pp. 51-76). New York: Wiley-Liss.
Dalton, A. J.. & Crapper-McLachlan, D. R. (1986). Clinical expression of Alzheimer's disease in
Down syndrome. Psychiatric Clinics of North America, 9, 659-670.
Dalton, A. J., & Wisniewski. H. M. (1990). Down's Syndrome and the dementia of Alzheimer dis-
ease. International Review of Psychiatry, 2, 43-52.
Dalton, A. J., Seltzer, G. B., Adlin, M. S., & Wisniewski. H. M. (1993). Association between
Alzheimer disease and Down syndrome: Clinical observations. In J. M. Berg. H. Karlinsky, &
A. ]. Holland (Eds.), Alzheimer disease, Down syndrome, and their relationship (pp. 53-69).
Oxford, England: Oxford University Press.
Davidson. P. w., Cain, N. N.• Sloane-Reeves, J., Kramer. B., Quijano, L., VanHeyningen, J., & Gie-
sow, V. (1992. November). Aging effects on severe behavior disorders in community-based
clients with mental retardation. Paper presented at the meeting of the Gerontological Society
of America, Washington, DC.
Davidson, P. W., Cain, N. N., Sloane-Reeves, J. E.. Van Speybroech. A., Segel, J., Gutkin, J., Qui-
jano,1. E., Kramer, B. M., Porter, B., Shoham, 1., & Goldstein, E. (1994). Characteristics of com-
munity-based individuals with mental retardation and aggressive behavioral disorders. Amer-
ican Journal on Mental Retardation, 98, 704-716.
Edelson, R. T. (1990). ART AND CRAFTS-Not "arts and crafts"-Alternative vocational day activ-
ities for adults who are older and mentally retarded. Activities. Adaptation & Aging, 15,
81-97.
Eklund. S. J., & Martz, W. 1. (1993). Maintaining optimal functioning. In E. Sutton, A. R. Factor,
B. A. Hawkins, T. Keller, & G. B. Seltzer (Eds.), Older adults with developmental disabilities:
Optimizing choice and change (pp. 3-27). Baltimore: Brookes.
Elliott, R. 0., Jr., Dobbin, M. A., Rose, G. D., & Soper, H. V. (1994). Vigorous, aerobic exercise versus
general motor training activities: Effects on maladaptive and stereotypic behaviors of adults
with both autism and mental retardation. Journal of Autism and Developmental Disorders, 24,
565-576.
Eyman, R. K., & Widaman, K. F. (1987). Life-span development ofinstitutionalized and community-
based mentally retarded persons, revisited. American Journal of Mental Deficiency, 91,
559-569.
Eyman, R. K., Call, T. L., & White, J. F. (1989). Mortality of elderly mentally retarded persons in Cal-
ifornia. Journal of Applied Gerontology, 8, 203-215.
Fenner, M. E., Hewitt, K. E., & Torpy, D. M. (1987). Down's syndrome: Intellectual and behavioural
functioning during adulthood. Journal of Mental Deficiency Research, 31, 241-249.
Fernhall, B. (1993). Physical fitness and exercise training of individuals with mental retardation.
Medicine and Science in Sports and Exercise. 25, 442-450.
Fine, M. A., Tangeman, P. J., & Woodard, J. (1990). Changes in adaptive behavior of older adults with
mental retardation following deinstitutionalization. American Journal on Mental Retardation,
94,661-668.
Fisher, M. A., & Zeaman, D. (1970). Growth and decline ofretarded intelligence. International Re-
view of Research in Mental Retardation, 4, 151-191.
Foelker, G. A., Jr., & Luke, E. A., Jr. (1989). Mental health issues for the aging mentally retarded pop-
ulation. Journal of Applied Gerontology, 8. 242-250.
Friman, P. C., Barnard, J. D., Altman, K., & Wolf, M. M. (1986). Parent and teacher use of DRO and
DRI to reduce aggressive behavior. Analysis and Intervention in Developmental Disabilities, 6.
319-330.
Fujiura, G. T., & Braddock, D. (1992). Fiscal and demographic trends in mental retardation services:
The emergence of the family. In L. Rowitz (Ed.), Mental retardation in the year 2000 (pp.
Gabler-Halle, D., Halle, J. W., & Chung, Y. B. (1993). The effects of aerobic exercise on psychological
and behavioral variables of individuals with developmental disabilities: A critical review. Re-
search in Developmental Disabilities, 14,359-386.
Gibson, J. W., Rabkin, J., & Munson, R. (1992). Critical issues in serving the developmentally dis-
abled elderly. Journal of Gerontological Social Work, 19,35-49.
Greenberg, J. S., Seltzer, M. M., & Greenley, J. R. (1993). Aging parents of adults with disabilities:
The gratifications and frustrations of later-life caregiving. Gerontologist, 33, 542-550.
Harper, D. C., & Wadsworth, J. S. (1990). Dementia and depression in elders with mental retarda-
tion: A pilot study. Research in Developmental Disabilities, 11, 177-198.
Harper, D. c., & Wadsworth, J. S. (1993). Grief in adults with mental retardation: Preliminary find-
ings. Research in Developmental Disabilities, 14,313-330.
Hewitt, K. E., Carter, G., & Jancar, J. (1985). Ageing in Down's syndrome. British Journal of Psychia-
try, 147, 58-62.
Hewitt, K. E., Fenner, M. E., & Torpy, D. (1986). Cognitive and behavioral profiles of the elderly
mentally handicapped. Journal of Mental Deficiency Research, 30, 217-225.
Hogg, J., & Moss, S. (1993). The characteristics of older people with intellectual disabilities in En-
gland. International Review of Research in Mental Retardation, 19, 71-96.
Jacobson, J. W. (1988). Problem behavior and psychiatric impairment within a developmentally dis-
abled population III: Psychotropic medication. Research in Developmental Disabilities, 9,
23-38.
Jacobson, S., &: Kropf, N. P. (1993). Facilitating residential transitions of older adults with develop-
mental disabilities. Clinical Gerontologist, 14, 79-93.
James, D. H. (1986). Psychiatric and behavioural disorders amongst older severely mentally handi-
capped inpatients. Journal of Men tal Deficiency Research, 30, 341-345.
Janicki, M. P. (1994). Policies and supports for older persons with mental retardation. In M. M.
Seltzer, M. W. Krauss, &: M. P. Janicki (Eds.), Life course perspectives on adulthood and old age
(pp. 143-165). Washington, DC: American Association on Mental Retardation.
Janicki, M. P., Heller, T., Seltzer, G., &: Hogg, J. (1995). Practice guidelines for the clinical assessment
and care management of Alzheimer and other dementias among adults with mental retarda-
tion. Washington, DC: American Association on Mental Retardation.
Jencks, S. F., &: Clausen, S. B. (1991). Managing behavior problems in nursing homes. Journal of the
American Medical Association, 265, 502-503.
Jenkins, E. L., Hildreth, B. L., &: Hildreth, G. (1993). Elderly persons with mental retardation: An ex-
ceptional population with special needs. International Journal of Aging and Human Devel-
opment, 37, 69-80.
Katz, S., Ford, B. S., Moskowitz, R. W., Jackson, B. A., &: Jaffe, M. W. (1963). Studies of illness in
the aged. The Index of ADL: A standardized measure of biological and psychosocial function.
Journal of the American Medical Association, 185 (12), 94-99.
Kerby, D. S., Wentworth, R., &: Cotten, P. D. (1989). Measuring adaptive behavior in elderly devel-
opmentally disabled clients. Journal of Applied Gerontology; 8,261-267.
Kultgen, P., &: Rominger, R. (1993). Cross training within the aging and developmental disabilities
service systems. In E. Sutton, A. R. Factor, B. A. Hawkins, T. Heller, &: G. B. Seltzer (Eds.),
Older adults with developmental disabilities: Optimizing choice and change (pp. 239-256).
Baltimore: Brookes.
Lakin, K. C., Anderson, D. J., Hill, B. K., Bruininks, R. H., &: Wright, E. A. (1991). Programs and ser-
vices received by older persons with mental retardation. Mental Retardation, 29, 65-74.
Lancioni, G. E., Brouwer, J. A., Bouter. H. P., &: Coninx, F. (1993). Simple technology to promote in-
dependent activity engagement in institutionalized people with mental handicap. Interna-
tional Journal of Rehabilitation Research, 16, 235-238.
Matson, J. L., &: Gardner, W. 1. (1991). Behavioral learning theory and current applications to severe
behavior problems in persons with mental retardation. Clinical Psychology Review, 11,
175-183.
McGrew, K. S., Ittenbach, R. F., Bruininks, R. H., &: Hill, B. K. (1991). Factor structure of maladap-
tive behavior across the lifespan of persons with mental retardation. Research in Develop-
mental Disabilities, 12, 181-199.
McVicker, R. W., Shanks, o. E. P., &: McClelland, R. J. (1994). Prevalence and associated features of
epilepsy in adults with Down's syndrome. British Journal of Psychiatry, 164, 528-532.
Menolascino, F. J., &: Potter, J. F. (1989). Mental illness in the elderly mentally retarded. Journal of
Applied Gerontology, 8, 192-202.
Meyers, C. E., Borthwick, S. A., &: Eyman, R. (1985). Place of residence by age, ethnicity, and level
of retardation of the mentally retarded/developmentally disabled population of California.
American Journal of Mental Retardation, 90, 266-270.
Mink, I. T., Nihira, K., &: Meyers, C. E. (1983). Taxonomy of family life styles. I: Homes with TMR
children. American Journal of Mental Deficiency, 87, 484-497.
Moon, M. S., &: Renzaglia, A. (1982). Physical fitness and the mentally retarded: A critical review of
the literature. Journal of Special Education, 16,269-287.
National Center for Health Statistics. (1979). The national nursing home survey: 1977 summary
for the United States. Washington, DC: United States Department of Health, Education, and
Welfare.
National Center for Health Statistics, Public Health Services. (1986). Prevalence of selected chronic
conditions, United States, 1979-1981. Vital and Health Statistics, Series 10, No. 155 (DHHS
Publ. No. (PHS) 86-1583). Washington, DC: U.S. Government Printing Office.
Neef, N. A., Bill-Harvey, D., Shade, D., Iezzi, M., &: DeLorenzo, T. (1995). Exercise participation with
videotaped modeling: Effects on balance and gait in elderly residents of care facilities. Behav-
ior Therapy, 26, 135-151.
Newbern, V. B., &: Hargett, M. V. (1992). A gerontological nursing issue: The aged developmentally
disabled/mentally retarded. Holistic Nurse Practitioner, 7,70-77.
Nihira, K., Foster, R., Shellhaas, M., & Leland, H. (1974). AAMD Adaptive Behavior Scale. Wash-
ington, DC: American Association on Mental Deficiency.
Nihira, K., Leland, H., & Lambert. N. (1993). Adaptive Behavior Scale-Residential and Community
(2nd ed.). Austin, TX: Pro-Ed.
Peterson, F. M., & Martens, B. K. (1995). A comparison of behavioral interventions reported in treat-
ment studies and programs for adults with developmental disabilities. Research in Develop-
mental Disabilities, 16, 27-41.
Pitetti, K. H., & Campbell, K. D. (1991). Mentally retarded individuals-A population at risk? Med-
icine and Science in Sports and Exercise, 23, 586-593.
Ray, W. A., Federspiel, C. F., & Schaffner, W. (1980). Antipsychotic drug use in nursing homes: Ev-
idence of misuse. American Journal of Public Health, 70, 485-491.
Redjali, S. M., & Radick, J. R. (1988). ICF/General: An alternative for older ICF/MR residents with
geriatric care needs. Mental Retardation, 26, 209-212.
Rinck, C., & Calkins, C. F. (1989). Patterns of psychotropic medication use among older persons
with developmental disabilities. Journal of Applied Gerontology. 8, 216-227.
Robakis, N. K., Wisniewski, H. M., Jenkins, E. C., Devine-Gage, E. A., Houck, G. E., Yao, X. L., Ra-
makrishna, N., Wolfe, G., Silverman, W., & Brown, W. T. (1987). Chromosome 21q21 sublo-
calization of gene encoding beta amyloid peptide in cerebral vessels and neurotic (senile)
plaques of people with Alzheimer's disease and Down syndrome. Lancet, 1 (8529), 384-385.
Schneider, L. S., Pollock, V. E., & Lyness, S. A. (1990). A metaanalysis of controlled trials of neu-
roleptic treatment in dementia. Journal of the American Geriatrics Society. 38, 553-563.
Seltzer, G. B., Finaly, E., & Howell, M. (1988). Functional characteristics of elderly persons with
mental retardation in community settings and nursing homes. Mental Retardation, 26,
213-217.
Seltzer, M. M. (1988). Structure and patterns of service utilization by elderly persons with mental
retardation. Mental Retardation, 26, 181-185.
Seltzer, M. M., & Krauss, M. W. (1984). Family, community residence, and institutional placements
of a sample of mentally retarded children. American Journal of Mental Deficiency, 89,
257-266.
Seltzer, M. M., & Krauss, M. W. (1987). Aging and mental retardation: Extending the continuum
(Monograph No.9). Washington, DC: American Association on Mental Retardation.
Seltzer, M. M., & Krauss, M. W. (1989). Aging parents with adult mentally retarded children: Fam-
ily risk factors and sources of support. American Journal on Mental Retardation, 94, 303-312.
Seltzer, M. M., & Krauss, M. W. (1994). Aging parents with coresident adult children: The impact
of lifelong caregiving. In M. M. Seltzer, M. W. Krauss, & M. P. Janicki (Eds.), Life course per-
spectives on adulthood and old age (pp. 3-18). Washington, DC: American Association on
Mental Retardation.
Seltzer, M. M., Krauss, M. W., Litchfield, L. C., & Modlish, N. J. K. (1989). Utilization of aging net-
work services by elderly persons with mental retardation. Gerontologist, 29, 234-238.
Seltzer, M. M., Krauss, M. W., & Tsunematsu, N. (1993). Adults with Down Syndrome and their
mothers: Diagnostic group differences. American Journal on Mental Retardation. 97,496-508.
Seltzer, M. M., Greenberg, J. S., & Krauss, M. W. (1995). A comparison of coping strategies of aging
mothers of adults with mental illness versus mental retardation. Psychology and Aging, 10,
64-75.
Shepard, R. J. (1987). Human rights and the older worker: Changes in work capacity with age. Med-
icine and Science in Sports and Exercise, 19, 168-173.
Smith, G. C., Fullmer, E. M., & Tobin, S. S. (1994). Living outside the system: An exploration of
older families who do not use day programs. In M. M. Seltzer, M. W. Krauss, & M. P. Janicki
(Eds.), Life course perspectives on adulthood and old age (pp. 19-37). Washington, DC: Amer-
ican Association on Mental Retardation.
Spitz, H. H. (1986). Disparities in mentally retarded persons' IQs derived from different intelligence
tests. American Journal of Mental Deficiency, 90, 588-591.
Spruill, J. (1991). A comparison of the Wechsler Adult Intelligence Scale-Revised with the Stan-
ford-Binet Intelligence Scale (4th edition) for mentally retarded adults. Psychological Assess-
ment, 3, 133-135.
Wersh, J., & Thomas, M. R. (1990). The Stanford-Binet Intelligence Scale: Fourth edition; Observa-
tions, comments, and concerns. Canadian Psychology. 31, 190-193.
Whitman, T. 1., Scibak, J. W., & Reid, D. H. (1983). Behavior modification with the severely and pro-
foundly retarded: Research and application. New York: Academic.
Wilhite, B., Keller, M. J., & Nicholson, L. (1990). Integrating older persons with developmental dis-
abilities into community recreation: Theory to practice. Activities, Adaptation & Aging, 15,
111-129.
Winokur, B. (1974). Subnormality and its relation to psychiatry. Lancet, 2, 270-273.
Wolfensberger, W. (1972). The principle of normalization in human services. Toronto. Ontario,
Canada: National Institute on Mental Retardation.
Zarit, S. H., Reever, K. E., & Bach-Peterson, J. (1980). Relatives of impaired elderly: Correlates of
feelings of burden. Gerontologist, 20, 649-655.
Zarit, S. H., Todd, P. A., & Zarit. J. M. (1986). Subjective burden of husbands and wives as care-
givers: A longitudinal study. Gerontologist, 26, 260-266.
CHAPTER 16
Behavioral Medicine
Interventions with Older Adults
MARY J. GAGE AND ANTHONY J. GORECZNY
INTRODUCTION
Behavioral medicine is an area that has flourished since the 1960s. In large part,
this is due to the fact that the primary conditions that have led to death and ill-
ness since then have involved significant psychosocial or biobehavioral risk fac-
tors (Goreczny, 1995b). Despite the growth in the area of behavioral medicine in
general, until recently there had been only very scant references to behavioral
medicine interventions with older adults. There may be several reasons for this.
First, many health care professionals shy away from treating older adults. Sec-
ond, some thought it difficult, if not impossible, to teach older adults the strate-
gies often used in behavioral medicine interventions, including techniques such
as biofeedback, relaxation training, and disease self-management. The view that
older adults cannot learn these techniques was prevalent among health care pro-
fessionals and prospective patients alike. Third, some initial research studies
provided apparent proof that older adults could not benefit from behavioral
medicine interventions. Thus, for quite some time, although researchers usually
did not exclude older adults from studies, there was very little attempt to study
this population independently of their younger cohorts. Studies that did include
older adults usually statistically adjusted for demographic factors such as age
rather than examining the effects of these factors outright.
With demographic data revealing that older adults comprise one of the
largest growing segments of the population, there has been an increase in inter-
est in conducting research with this population. Much of the research still con-
founds data from older and younger adults, thereby making it impossible to
MARy J. GAGE • Mellon Center. Cleveland Clinic. Cleveland. Ohio 44195 ANTHONY J. GORECZNY
• Director of Clinical Training Program, Department of Psychology. University of Indianapolis.
Indianapolis. Indiana 46227-3697.
351
352 Mary J. Gage and Anthony J. Goreczny
delineate effects of interventions specifically on older adults. Nonetheless,

some excellent studies have begun to isolate these effects. In this chapter, we re-
view only those studies that permit a clear appraisal of intervention effects on
older adults or that have significant implications for these individuals.
The field of behavioral medicine includes many areas; in this chapter, we
address only a few. Some of the areas that might fall under the rubic of be-
havioral medicine appear elsewhere in this book: Chapter 12 deals with sexual
dysfunction, Chapter 13 with sleep disorders, Chapter 18 with pain manage-
ment, and Chapter 24 with physical activity. Therefore, we do not address those
topics in this chapter. Instead, we focus our attention on issues related to stress,
HIVI AIDS, health maintenance, and smoking, and on two issues of special im-
portance to older adults, specifically, falls and tremors. In these areas, we have
provided a brief overview of recent research regarding the topic. Because of the
rapidly growing database, we focus almost exclusively on research published in
the 1990s.
This chapter provides a primer for readers rather than a comprehensive re-
view; it is intended to spark the interest of readers to further investigate this excit-
ing area. Those who develop such as interest might want to consult the book by
Goreczny (1995a), which deals comprehensively with a wide variety of behavioral
medicine and health psychology topics but without the emphasis on older adults.
STRESS
The area of stress is an area that, in general, needs much work just to define
the topics of study. What constitutes stress and how to measure stress are just
two of the many questions that lack definitive answers. Nonetheless, stress re-
mains one ofthe largest areas of research in the behavioral sciences. Since 1985,
there have been more than 1,500 published articles each year that have become
part ofthe PsycLit database (Goreczny, 1997). This represents more than 4% of
all such articles each year. Fortunately, the area of stress as it pertains to older
adults has also received significant attention. As will be clear from the literature
review below, however, much work and many questions remain.
One of the first and most obvious questions to ask is whether the numbers
and types of stressors are different among older and younger adults. Certainly,
one would expect that the types of stressors older adults experience are differ-
ent from the types of stressors experienced by younger cohorts. One of the stres-
sors that older adults are more likely to experience than are younger adults is
the death of a spouse or even of an adult child. One recent study revealed that,
as one would expect, bereavement has significant stress effects on older adults
who experience such losses (Arbuckle & de Vries, 1995). There is, however,lit-
tle recent research that addresses the question as to differences in type of stres-
sors among older and younger adults. There is also very little, if any, recent
research that addresses the question of whether the number of stressors experi-
enced by older adults differs from the number experienced by younger adults.
Most of the recent research in older adults has focused on stress effects and cop-
ing. It is to this literature that we now turn our attention.
The effects of stress on health-related problems in the general population
are quite clear, so much so that "stress management has become a universally ac-
Behavioral Medicine Interventions with Older Adults 353
cepted form of health intervention and has improved the quality of life for many
individuals" (Brantley & Thomason. 1995. p. 286). There have been several stud-
ies that have looked specifically at the effects of stress on the health of older
adults. In one study. Krause (1996) noted that the stress of living in deteriorated
living environments and neighborhoods contributes to an increase in self-re-
ported physical health problems among older adults. relative to older adults who
live in neighborhoods that have not experienced significant deterioration.
Krause noted that this relationship is present only for the extremely deteriorated
neighborhoods. however, and attributed the stress-health connection in this
case to a breakdown and weakening of friendships. Research by Kahana. Red-
mond. Hill, & Kircher (1995) is consistent with this attribution. In Kahana and
colleagues' study, the authors obtained a variety of measures from 397 adults
more than 54 years of age. One of the main conclusions from this study was that
the effect of stressors on well-being in this population came via an indirect
mechanism-satisfaction with various domains of the individuals' lives. In ad-
dition to overall self-rated health. studies have revealed likely stress effects on
specific physiological functions of older adults, including potentiation of age-re-
lated decreases in testicular functioning among men (Vermeulen. 1994).
Additional research has attempted to examine effects of stress on normal
activities of daily living among adults. For example, there has been some indi-
cation of deleterious stress effects on sleep. Friedman et al. (1995) found a pos-
itive association between amount of stress and amount of sleep difficulty
among a group of older adults. This relationship, however, was present only in
a group of poor sleepers and not in a group of good sleepers. Though there was
this within-group relationship between number of stressors and amount of
sleep, there was no difference between the group of good sleepers and the group
of poor sleepers with regard to amount of stress. Thus. the specific role of stres-
sors in problems of sleep among older adults remains unknown.
Still other researchers have attempted to implicate stressors as significant
factors in the onset of late-life alcoholism as well as dementia. For example. al-
though research by Liberto and Oslin (1995) suggested that late-onset alcoholics
tend to have greater psychological stability than do early-onset alcoholics. this
research has also suggested that late-life stress may be one factor contributing
significantly to late-onset alcohol problems. However. Krause (1995b) also noted
that alcohol use may serve a beneficial role among older adults: Alcohol may
mitigate effects of minor stressors. Of importance, though. is that alcohol tends
to increase effects of highly significant stressors among older adults. Some re-
searchers have also attempted to implicate stress in the development of demen-
tias (see Carpenter, Strauss, & Kennedy, 1995). However, there is evidence that
stress experienced by patients suffering from dementia may be the result of dis-
ruption of their social lives as a consequence of the disorder rather than a con-
tributing factor to development of the disorder (Ortell & Bebbington, 1995).
Interestingly, recent research has revealed that older adults appear to han-
dle stressors better than do younger adults (Carmack et a1., 1995). In a recent
study by Nussbaum and Goreczny (1995), one ofthe interesting findings was
that there was a significant negative relationship between age and self-reported
level of overall stress. Thus, older adults reported feeling less stressed in gen-
eral than did younger adults. Other recent research is consistent with this find-
ing. In a study by Talbert, Wagner, Braswell, and Husein (1995), older adults
were the least susceptible age group with regard to experiencing stress symp-
toms in response to an emergency room visit. Also consistent with this is a re-
cent study revealing that low-functioning fibromyalgia patients tended to be
younger than their higher-functioning cohorts (Schoenfeld-Smith. Nicassio.
Radojevic. & Patterson. 1995). Finally. Rose and West (1996) noted that among
cardiac rehabilitation patients. younger patients presented with more depres-
sion than did older patients.
Several researchers have investigated the stress effects and coping strate-
gies used by individuals suffering from chronic illnesses. One model frequently
cited as explaining psychological adjustment to stressors is the stress and cop-
ing model proposed by Lazarus and Folkman (1984). One recent study revealed
that such a stress and coping model appears to be applicable specifically to
older adults as well as to the general population (Landreville. Dube. Lalande. &
Alain. 1994). In this study. the authors found a positive relationship between
amount of perceived stress among older adults suffering from mobility limita-
tions and the amount of coping efforts they made. Interestingly. subjects who
used coping strategies of taking on increased amounts of responsibility or at-
tempting to escape or avoid stressors. or both. reported high levels of perceived
stress and a large number of depressive symptoms. .
Some other researchers have also attempted to investigate stress effects
specifically among older adults with chronic illnesses. As one example. Melan-
son and Downe-Wamboldt (1995) noted that their sample of older adults suf-
fering from rheumatoid arthritis identified several illness-related stressors
associated with the condition. However. those subjects also reported utilizing
active. confrontative types of strategies to help them cope with the identified
stressors. Interestingly, in another study, the same investigators reported that
higher socioeconomic status clients tended to utilize active, confrontative cop-
ing strategies more often than did lower socioeconomic status clients (Downe-
Wamboldt & Melanson, 1995).
Life stressors frequently result in the manifestation of anxiety symptoms.
On the other hand, anxiety symptoms may also be due to some specific illness
or disease process. Given that with aging comes an increasing likelihood of de-
veloping an illness that has an identified physiological process, it is especially
important to rule out specific organic pathology among older adults. Hocking
and Koenig (1995) discuss the importance of proper diagnosis prior to imple-
menting treatment for older adults who report anxiety symptoms. Treatment
will then depend upon etiological considerations. If no identified physiological
process appears to be contributing to the anxiety symptoms. assessment can
progress along the lines of attempting to ascertain whether the symptoms rep-
resent an anxiety disorder, per se. or the response to life stressors. Treatment
would proceed accordingly. However. assessment of anxiety among older
adults represents a challenging endeavor because of the limited amount of data
available for this population (Hersen. Van Hasselt, & Goreczny. 1993).
As is the case with anxiety, depressive symptoms in older adults may be due
to stressors or to some other factor. Some investigators have posited a stress-
diathesis model to account for depression among older adults and to emphasize
the importance of taking into account the complex interaction of biological. so-
cial. and psychological factors (e.g .• Carpenter et a1.. 1995; Rossen & Buschmann.
1995). This type of model addresses the potential role of both environmental and
neurobiological variables in the etiological conceptualization of depression. Re-
cent research has been largely consistent with this postulation. For example, one
recent study revealed that mild depressive symptomatology in older adults may
be due to stressors but that major depressive disorders are likely to be exacerba-
tions of a long-term vulnerability to mood disturbances (Beekman, Deeg, van
Tilburg, Smit, Hooijer, & van Tilburg, 1995). Thus, older clients with major de-
pressive symptoms are likely to have suffered from depressive symptoms previ-
ously in their lives and new-onset depressive symptoms among patients who
previously suffered from depression thus represent a pattern of mood fluctua-
tions rather than a reaction to life stressors. It is wise, nonetheless, to conduct a
full biopsychosocial assessment of older adults when new depressive symptoms
recur, because of the possibility that such depressive symptoms may have re-
sulted from recent psychosocial changes in that client's life or may be due to a
new-onset illness or physiologically based disease process (e.g., cancer).
Thus, research on assessment of stress with older adults is largely consis-
tent with the stress literature in general. Older adults tend to utilize a variety of
coping strategies and experience reactions to stressors similar to those of
younger adults. Similarly, research has revealed that, like younger adults, social
support of older adults has an initial positive effect but that increased social
support over prolonged periods of time may result in increased psychological
difficulties (Krause, 1995a). Older adults appear to suffer from stress-related
problems less than do younger adults. Research needs to identify the reasons
for this difference. Possible explanations are that (a) older adults have learned
which coping mechanisms work best for them and how to best implement those
strategies; (b) older adults have learned how to selectively choose which chal-
lenges to accept and which challenges to reject, thereby experiencing fewer but
more rewarding stress challenges than those of younger adults; (c) older adults,
relative to their younger cohorts, have fewer stressors imposed upon them (e.g.,
less concern about children, more stable interpersonal relations); or (d) younger
adults who coped with stress poorly died as a consequence of stress-related dis-
ease processes. In contrast to the self-report data, recent psychophysiological
data indicate that older adults respond to stressors more strongly than do
younger adults (Goreczny, Keen, & Walter, 1997). In conclusion, there is much
research needed to identify the process of stress interpretation across the life
span and to determine why older adults appear to report less stress and anxi-
ety but evidence greater psychophysiological reactivity to stressors than do
younger adults. Such information may help all age cohorts.
There is very little research on stress management or treatment of older
adults. However, one recent and very promising study revealed that stress
inoculation training tends to have positive short- and long-term effects on
measures of cognitive functioning (Hayslip, Maloy, & Kohl, 1995). Additional
research is necessary to verify these data. Also, although there is a fair amount
ofresearch on the stress of caring for older adults, including those with demen-
tia or other problem areas; this remains an important area for additional re-
search because of the aging population. Contributing to this is the fact that older
adults with ill parents will likely experience more stress than younger adults
with ill parents because of the need of the older adults to deal with their own
physical problems. On the other hand, younger adults may have their families
to raise, feel less financially secure, and have more tentative interpersonal rela-
tionships than do older adults. Thus, future research will need to address the
many issues of caregiver stress that remain unknown.
HEALTH PROFMOTION AND

HEALTH MAINTENANCE
Although there has been an increase of interest in helping older adults who
are already suffering some type of physical malady, very few studies have in-
vestigated the effects of health promotion services to older adults. This is de-
spite the fact that several studies have revealed significant relationships
between age and health protective behaviors (e.g., Jones, Greaves, & Iliffe, 1992)
and that there is a clear relationship between age and manifestation of disease
(Brackstone, Delehunty, Mann, & Pain. 1995). Most important for health psy-
chology is that specific lifestyle factors associated with survival differ based on
age (Davis, Neuhaus, Moritz, Lein, Barclay, & Murphy, 1994).
A study by Ma and Chi (1995) evaluated health promotion services for
older adults. The authors invited clients to participate in a health counseling
service; as part of this service, clients attended small group meetings and indi-
vidual counseling sessions. Group sessions were available for a variety of con-
ditions, including hypertension, diabetes, obesity, and hypercholesteremia.
Clients learned to take some control of their health by first monitoring and
recording health-associated variables.
Unfortunately, as indicated previously, the literature contains very few re-
cent references to health promotion efforts aimed at older adults. In the next
few sections. we briefly review some of the relevant issues related to obesity,
eating disorders, Type A behavior, and smoking. Of these, only smoking has any
significant recent literature that pertains to older adults.
Obesity
A recent literature search revealed no studies that have evaluated obesity

treatment programs specifically with older adults. This is surprising in light of
recent data that indicate obesity is one of the risk factors for disability among
older ambulatory women (Ensrud et a1., 1994). Other factors associated with
disability in this cohort of women included physical inactivity, smoking, and
alcohol abuse. Of particular note, the study examined only non-Black women;
thus, the generalizability of these findings to the African American population
remains unknown. Lack of data on obesity among older adults is especially sur-
prising given that several studies have linked development of obesity to
menopause in women (Abraham, Llewellyn-Jones, & Perz, 1994; Huerta, Mena,
Malacara, & Diaz-de-Leon, 1995) and that obesity is one of the primary factors
related to lipid levels in postmenopausal women (Laws, King, Haskell, &
Reaven, 1993). These data indicate a need to address the issue of obesity in
older adults.
Eating Disorders
Although incidence of eating disorders is likely to be very low among older

adults, there have been some reported cases. In one case, Riemann, McNally,
and Meier (1993) reported on the case of a 72-year-old man who had a 20-year
history of an apparent eating disorder. Symptoms included chronic fears of be-
coming overweight, distorted body image, and very low weight (95 pounds).
The authors had administered a battery of questionnaires to the patient, and his
scores on these questionnaires were consistent with scores obtained from pa-
tients who have confirmed diagnoses of anorexia nervosa.
There have been several such cases in the recent literature (Fenley, Powers,
Miller, & Rowland, 1990; Gowers & Crisp, 1990; Hall & Driscoll, 1993; Morley,
1993), and a question of whether eating disorders among older adults deserves
recognition as a distinct diagnostic entity has arisen (Lee, 1992; Russell &
Gilbert, 1992). This view is supported by some research that has implicated
brain metabolism in the pathogenesis of anorexia among older adults (Martinez,
Arnalich, Vazquez, & Hernanz, 1993). However, a recent literature review ofthe
topic indicated that older adults with eating disorders share most all of the
same features as their younger cohorts (Cosford & Arnold, 1992).
Given that there are clearly some cases of eating disorder among the older
adult population, studies evaluating incidence of eating disorders in this popu-
lation are warranted. It is possible that health care professionals overlook pres-
ence of eating disorders among older adults because of the presumed low base
rates or because they attribute it to a specific disorder frequently found in later
life rather than as a distinct problem. Some recent research has indicated that a
large number of older adults admit to problems related to self-control of food in-
take (Miller, Morley, Rubenstein, & Pietroszka, 1991). These and related factors
have led some investigators to question whether eating disorders are indeed
more prevalent than previously considered (Cos ford & Arnold, 1991).
Type A Behavior
Despite the large amount of work on the Type A behavior pattern and the
effects of hostility on health, especially cardiac conditions (Smith, 1995), there
exists very little work on Type A behavior with older adults. This is especially
surprising given that some research has found increased hostility and competi-
tiveness among Type As as they age (Carmelli, Dame, & Swan, 1992). Older
adults who report that their middle-age environment was a Type A challenging
form of environment are more likely than those who do not report such an en-
vironment to have diseases associated with advancing age (Kopac, 1990). Given
these facts, it is remarkable that only a limited amount of current work on Type
A behavior with older adults is available. The extant studies for the most part
continue to support the notion of Type A behavior and hostility as contributing
factors to physical problems. For example, in a study by Vitaliano, Russo, and
Niaura (1995), Type A behavior and various forms of anger-related problems
contributed significant variance to measures of triglycerides and both high- and
low-density lipoproteins.
The role of expressed emotion in the physical factors of older adults may
prove to be a fruitful avenue for future research. Some research has indicated.
that older adults tend to be more emotionally expressive than younger adults
(Malatesta-Magai, Jonas, Shepard, & Culver, 1992) and tend to respond with
greater cardiovascular responses to emotional tasks than to cognitive ones (Vi··
taliano, Russo, Bailey, Young, & McCann, 1993). Also. future research must fo··
cus on the interaction between stress and Type A behavior among older adults.
For example, one study revealed that Type A individuals tend to experience
more involuntary retirement than do non-Type As (Swan. Dame. & Carmelli.
1991). Given the stress ofretirement and generally poorer adjustment to invol-
untary than voluntary retirement. it would be reasonable to hypothesize that
Type As forced to retire would be at greatest risk for physical and psychosocial
problems. Surprisingly, there appear to be only minimal physical and psy-
chosocial differences between Type As who retire voluntarily and those who re-
tire involuntarily (Swan et al., 1991). Thus, it is clear that additional research
needs to clarify the relationship among Type A behavior, stress. anger, physical
problems, and psychosocial difficulties among older adults.
Smoking
Smoking is one of the leading risk factors contributing to death in the

United States and Western European countries. Among older adults, it remains
a risk factor or complicating factor for 9 of the 14 primary causes of death (Fin-
cham, 1992). However, one paper notes that smoking is a risk factor for prema-
ture death among women but not men (Samuelsson, Hagberg, Dehlin, &
Lindberg, 1994). Despite this inconsistency, it is clear that smoking remains a
significant risk factor for health problems. and that this is the case for older
adults as well as for the population in general.
In addition to the well-known risks associated with smoking, such as heart
attack and stroke, one recent study (Nelson. Nevitt. Scott, Stone. & Cummings.
1994) revealed that older women smokers, relative to nonsmokers, tend to be
weaker and have a number of physical or physiological difficulties; these diffi-
culties, which may also contribute to the weakness. include neuromuscular
performance impairment and poor balance. This study is consistent with earlier
research studies, which have revealed an association between smoking and dis-
ability among older women (Ensrud et al .. 1994) and between smoking and
measures of lung functioning among older men (Bosse, Sparrow, Garvey. Costa,
Weiss. & Rowe, 1980). In addition, smoking is a significant predictor of lipid
levels among postmenopausal women (Laws et al., 1993), and increased lipid
levels may place one at risk of heart attack. Fincham (1992) also confirmed that
smoking affects many organ systems, including the respiratory and cerebrovas-
cular systems. Thus, numerous research studies have confirmed a strong asso-
ciation between smoking and various physiological parameters.
In addition to direct physiological consequences associated with smoking,
smoking may also affect health and health quality indirectly. For example,
among older adults, smoking relates to an increased need for and use of med-
ication as well as impaired quality of life (Jensen, Dehlin, Hagberg, Samuelsson,
& Svenson, 1994). Smoking also relates to other health risk behaviors, such as
lowered probability of adhering to health care providers' requests to have a

mammogram (Taplin. Anderman. Grothaus, Curry, & Montano, 1994) and an in-
creased likelihood of severe drinking problems (Nakamura, Molgaard, Stanford,
Peddecord, Morton, Lockery, Zuniga. & Gardner. 1990). In one study that eval-
uated smoking behavior in a long-term care facility, the authors concluded that
nearly 20% of smoking interactions involved behaviors that put people at risk
(Barker. Mitteness, & Wolfsen, 1994). Foster (1992) found that among older
African Americans there is an inverse relationship between number of ciga-
rettes smoked and health promoting behaviors. Also, though the implications
are unclear, a recent study revealed an association between smoking status and
specific food and food supplement intake (Itoh & Suyama, 1995). Japanese
smokers tended to have a lower intake of plant foods than did nonsmokers
(Suyama & Itoh, 1992). Other studies have also shown that smoking status is a
predictor of specific nutrient intake (Zipp & Holcomb, 1992) Finally, smokers
tend to evidence more depression symptomatology than do nonsmokers (Col-
sher, Wallace, Pomrehn, La Croix, Coroni-Huntley, Blazer, Scherr, Berkman, &
Hennekens, 1990; Salive & Blazer, 1993) and smoking is a risk factor for future
development of depression among older adults (Green. Copeland, Dewey,
Sharma, Saunders, Davidson. Sullivan, & McWilliam, 1992).
The studies just cited make implications of smoking among older adults
quite clear. One important question to address is the rate of smoking among
older adults versus that of younger adults. The literature suggests that older
adults tend to be less likely to smoke than younger adults (Maxwell & Kirdes,
1993). Consistent with this, a recent study revealed that among Chinese men
aged 15 to 65. rates of smoking reached a peak among the group of men in the
36-45 age range and then began to decline (Wei, Young, Lingiang, Shuiyuan.
Jian, Hanshu, Zhunghong, Xiouying, & Xudong. 1995). Unfortunately, the au-
thors did not evaluate rates of smoking beyond age 65. Though these data pro-
vide some good news regarding smoking among older adults. not all
information is positive. For example, although physicians have a lower rate of
smoking than the general population, older physicians are more likely than
younger physicians to be current or former smokers (Hensrud & Sprafka, 1993).
In addition, among older adults who smoke, there is a high rate of nicotine ad-
diction (Orleans et ai., 1991). Also, in Orleans and colleagues' study, older
adults reported a variety of concerns as barriers to quit attempts; these concerns
centered around loss of pleasure associated with cigarette smoking, likelihood
of cigarette cravings, and increased nervousness or irritability. As with younger
adults. prior and recent attempts at quitting related to quit contemplations.
Thus, these studies indicate that there is a significant need to investigate fac-
tors related to smoking cessation among older adults. The literature contains
many examples of studies that have addressed smoking cessation attempts and
factors related to these attempts specifically among older adults. For example, a
recent study of older rural adults receiving Medicare benefits provided several in-
teresting and informative conclusions (Lave, Ives, 'fraven, & Kuller, 1995). Most
interesting is that the study revealed that rural, older adults will take advantage of
opportunities to participate in health promotion activities and that the likelihood
of doing so increases if they receive encouragement to do so by their physicians.
This study also revealed that there is a positive relationship between participa-
tion in health prevention services and education level. A second study indicated
findings similar to those of Lave and colleagues. In this second study, older adults
who received only minimal preventive health care showed a higher rate of smok-
ing cessation as compared with a control group who received nothing other than
usual care. However, this difference in quit rates was not statistically significant
(Burton, Paglia, German, Shapiro, & Damiano, 1995). Notably, Fincham (1992) in-
dicated that many treatments used by the general population also tend to have
positive effects among older adults. Thus, smoking cessation attempts must re-
main a priority for older adults as well as for younger adults.
Recent research has attempted to determine whether age is a factor associ-
ated with quit attempts and successes. For example, one group of authors found
that among patients hospitalized for nonterminal and nonpregnancy reasons
older smokers were more likely than younger smokers to quit smoking and re-
main free from smoking upon follow-up (Glasgow, Stevens, Vogt, & Mullooly,
1991). Consistent with this study is a large telephone survey (13,031 subjects),
in which Pierce, Giovino, Hatzindreu, and Shopland (1989) found that older
smokers (> 65 years of age) were more likely than younger adult smokers to at-
tempt to quit and remain abstinent. Interestingly and somewhat inconsistently,
younger women appear more willing to make smoking cessation attempts than
do older women. In large-scale population-based surveys, it is clear that most
older men are former or current smokers while most older women never
smoked (Colsher et a1., 1990). Among older adults with smoking histories, men
are more likely than women to have quit (Colsher et a1., 1990). Finally, a study
by Lichtenstein and Hollis (1992) found that older smokers who smoked a rela-
tively large amount were more likely than other patients seen by their primary
care provider to attend a group smoking cessation program. Thus, it is clear that
age and sex do playa role in smoking cessation attempts. In general, most re-
search shows that older smokers are more likely than younger smokers to at-
tempt to quit and that men are more likely to have been smokers than older
women. This latter finding is probably due to prevailing societal norms 40 to 50
years ago, when these subjects would likely have begun smoking.
The relationship of age to smoking cessation attempts is quite interesting.
Part of the reason for younger adult smokers to make fewer attempts to quit and
have less success than older smokers is that younger smokers tend to have a
greater denial of average risk of developing a smoking-related disease than do
older smokers (Lee, 1989). This helps explain why African American older
adults with cardiovascular disease tend to report behavior modification attempts
related to stopping smoking (Hamm, Bazargan, & Barbre, 1993). When faced with
occurrence of a smoking-related disorder, it is hard for denial to remain intact.
With denial broken down, patients must face the likelihood that their smoking
may be harmful. Another interesting finding, however, is that the factors (e.g.,
education level) that predict smoking cessation at various stages of change differ
depending upon the age of participants (Kviz, Clark, Crittenden, Warneeke, &
Freels, 1995). The implication ofthis is that producing successful smoking ces-
sation programs may require inclusion of different components based not just on
stage of change but also on participants' ages. Several studies have provided
support for this notion by showing that motivation for smoking differs between
younger and older adult smokers (Dei, Tilley, & Gow, 1991; Zaimov, Fertcheva, &
Vanev, 1994). Similarly, reasons for participating in a smoking cessation program
differ between older and younger adults (O'Hara & Portser, 1994). Older adults
who receive self-help materials tailored specifically to them rate those materials
relatively high, and the use of these materials may enhance quit rates (Rimer, Or-
leans, Fleisher, & Cristinzio, 1994). Unlike their younger counterparts, older men
who quit smoking tend to lose weight whereas younger men who quit smoking
tend to gain weight (Bosse, Garvey, & Costa, 1980).
A recent study revealed that people who successfully quit smoking tend to
learn about self-help programs at work (Lefebvre, Cobb, Goreczny, & Carleton,
1990). One ofthe possible reasons for the success of workplace programs is that
workers may find support systems to aid in their attempts. Because most older
adults are obviously more likely to have retired from work than are younger
adults, older adults may have to seek out support systems not in place at the
worksite. Also problematic is that among smokers joining a community-wide
contest to quit smoking, contestants are likely to be younger rather than older
(Cummings, Kelly, Sciandra, & De Loughry, 1990). However, older adults who
enlist the assistance of a buddy to provide support in their attempt to quit tend
to be twice as likely to quit as do those patients who do not enlist this type of
support (Kviz, Crittenden, Clark, & Madura, 1994). Thus, these studies suggest
that in order for older adults to obtain the support they need to begin and main-
tain a smoking cessation program, future clinical research efforts will need to
address ways of building in social support mechanisms that will encourage
smoking cessation among older adults.
It is also clear that psychological factors playa role in smoking behavior
among older adults. For instance, there is an inverse relationship between self-
efficacy and health risk among older adults (Grembowski, Patrick, Diehr,
Durham, Beresford, Kay, & Hecht, 1993). In particular, high self-efficacy among
older adults, relative to low self-efficacy among this population, relates to a
greater likelihood of contemplating quitting smoking (Orleans et al., 1991).
Also, older women with high depressive symptomatology are nearly four times
as likely as older women without depression to quit smoking (Salive & Blazer,
1993). These studies indicate a need to examine how psychological factors and
disorders influence smoking behavior among older adults.
Other Areas
One area within the broad area of health promotion that has not received
sufficient attention in the literature is behavioral treatment of hypertension in
older adults. In a national survey, Tuthill (1989) found that age was the pri-
mary variable related to development of hypertension, with social variables
showing no or only weak relationships to hypertension. Tuthill concluded
that social stress may have little effect on development of hypertension. This
conclusion is inconsistent with much of the literature (Pickering, 1995).
Thus, research must focus on identifying factors that may be contributing to
the inconsistent results and on evaluating the use of behavioral treatments
(e.g., relaxation, biofeedback) with older adults who have hypertension.
These treatments may be effective for newly diagnosed cases but ineffective
for patients in whom long histories of hypertension have led to permanent
physiological changes or damage resulting from long-term high pressures on
the arteries.
Another area that may prove promising is the area of health risk assessment
among older adults. Of particular interest is the recent development of the Se-
niors' Life-style Inventory (Schwirian, 1991-1992). The scale consists of 26
items that measure health behaviors, and initial reliability data appear satisfac-
tory. However, additional research on the reliability and validity of this instru-
ment is necessary before its utility is certain.
HIV/AIDS
There has been little focus on HIV infection among older adults because of
the perception that AIDS is a disease of younger adults. One presumption is that
older adults are less sexually active than younger adults and they, therefore, have
less risk of contracting HIV. Recent data from a national survey of 2,058 adults
suggest that older adults do indeed tend to be less sexually active than their
younger cohorts (Leigh, Temple, & Trocki, 1993). However, data also indicate that
approximately 10% of patients diagnosed with AIDS are 50 years of age or older
(Gutheil & Chichin, 1991). Some investigators have actually argued that older
adults may be at equal or increased risk, relative to their younger cohorts, for con-
tracting HIV infection (e.g., Whipple & Scura, 1989). Such a view argues for spe-
cific attention to focus on HIV among older adults. One reason to do this is that
age serves as a predictor of progression of the infection and survival among pa-
tients undergoing zidovudine therapy (Vella, Giuliano, Floridia, Chiesi, Tomino,
Speber, Bacherini, Bucciardini, & Mariotti, 1995). Linsk (1994) also discusses the
importance of screening HIV serostatus of older adults. The rationale for such use
is the increasing number of older adults who have developed HIV infections.
Linsk also addresses several other issues in relation to this matter that are typical
for HIV infection in the general population. These issues include pretest and
posttest counseling, prevention and treatment issues, and the importance of fam-
ily support. Therefore, it is indeed important to assess HIV infection among older
adults as well as to assess the effect of age on treatment outcomes.
Because of a recognition of the importance of addressing HIV and AIDS
among older adults, several groups of investigators have noted how essential it
is that we begin developing policies and prevention strategies aimed specifi-
cally at this population (Adamchak, Wilson, Nyanguru, & Hampson, 1991; Ben-
jamin, 1988; Talashek, Tichy, & Epping, 1990). Lloyd (1989) raised the concern
that, with research monies becoming increasingly difficult to obtain, older
adults and younger patients with HIV infection may compete for research
monies and other resources. Lloyd argued that older adults, having grown up in
conservative times, may have difficulty being sympathetic to those affected by
AIDS, whereas younger adults (those typically affected by AIDS) are likely to
view older adults with less respect than they view those from their own age
group. This sets the stage for a possible competition for resources between two
groups that are both in need of increased clinical and research priorities. How-
ever, this is not consistent with data indicating that older adults may, in fact, be
more sensitive to issues surrounding AIDS than are younger adults (B. E. Robin-
son, Walters, & Skeen, 1989).
Independent of the funding issues just discussed, one important component
of research with HIV is the assessment of risk behaviors. One aspect of address-
ing HIV risk requires that patients answer questions about their sexual behavior
and other potential risk factors. Despite some concerns that older adults might
be less open to questions about sexual behavior than are younger adults, a recent
study refuted this concern (Wiederman, Weis, & Allgeier, 1994). However, there
is only one recent study that has addressed identification of risk factors associ-
ated with HIV infection specifically among older adults. This study focused on
drinking behavior. Results indicated that heavy drinkers of all ages are more
likely than nonheavy drinkers to report engaging in high-risk sexual behaviors,
and regardless of drinking behavior, younger subjects are more likely than older
subjects to engage in high-risk sexual behaviors (Shillington, CottIer, Compton,
& Spitznagel, 1995). Thus, this study adds evidence that younger adults are more
likely than older adults to engage in behaviors that risk contracting HIV. How-
ever, it is still important to identify those older adults who place themselves at
risk and to attempt to intervene so as to decrease their chances of contracting
HIV. Part of the problem is that younger adults appear to have more knowledge
than do older adults regarding AIDS preventive measures (Dekker & Mootz,
1992). However, older adults appear more likely than younger adults to change
their lifestyles with regard to sexual behavior (Vincke, Mak, Bolton, & Jurica,
1993). Thus, intervention to reduce risk of infection may be more successful
with older adults than it has been with younger adults but this intervention re-
quires education to help older adults learn about preventive measures.
Beside the usual problems associated with HIV infection, age brings an ad-
ditional factor that highlights the need to work with older adults who have con-
tracted HIV. A recent study (Piette, Wachtel, Mor, & Mayer, 1995) revealed that
older adults with HIV score lower than younger adults with HIV on a variety of
quality of life domains, including health perception, mental health, and several
functioning domains (i.e., physical function, role function, and social function).
After controlling for CD4 lymphocyte count, all variables except role function
and mental health remained statistically significant. Surprisingly, older subjects
reported feeling less pain than did the younger subjects in the study. Also,
somewhat inconsistent with results from Piette and colleagues's study, are data
that indicate that older age relates to lower levels of depression (Vincke &
Bolton, 1994). Whether this is a real effect or an effect based on difficulties mea-
suring depression among older adults remains unknown.
An important issue related to HIV infection among older adults is the de-
velopment of cognitive difficulties. Younger adults with HIV encephalopathy
and older adults without diagnosed neurological disease have similar patterns
of results on neuropsychological tests. There are several studies that have
highlighted the effect of age on cognitive functioning of individuals infected
with HIV. One ofthese (Van Gorp, Miller, Marcotte, Dixon, Paz, SeInes, Wesch,
Becker, Hinkin, & Mitrushina, 1994) primarily evaluated measures of reaction
time along with some other timed neuropsychological tests. A recent study
compared performance of individuals with various types of dementias on neu-
ropsychological test performance and found that subjects who were in the
early stages of AIDS dementia primarily evidenced difficulties in the areas of
storage and retrieval, a pattern of results that is consistent with the pattern of
test results typical for older adults who are aging without significant neuro-
logical impairment (Mitrushina et 01.,1994). These data and those of Hinkin et
al. (1990), Kernutt, Price, Judd, & Burrows, (1993), and Van Gorp, Wilifred,
Mitrushina, Cummings, & Satz (1989) are consistent with AIDS dementia as
representing a subcortical dementia. This is an important issue because as-
sessment of AIDS among older adults may be difficult due to similarity of
many of the symptoms with those symptoms associated with dementia and
other disorders oflater life (Rosenzweig & Fillit, 1992; Scura & Whipple, 1990).
Patients with AIDS or who are HIV positive may simply be exhibiting the neu-
rological signs associated with the disorder, and bias among health care pro-
fessionals may limit the ability of these professionals to consider HIV infection
among older adults. Fortunately, emergence of single photon emission tomog-
raphy (SPET) technology has the potential to significantly improve the assess-
ment and diagnosis of AIDS dementia (Beats, Burns, & Levy, 1991).
ISSUES OF PRIMARY RELEVANCE

TO OLDER ADULTS
Tremors
Tremors represent a problem primarily associated with older age and with
disorders that develop with advancing age. One study (Moghal, Rajput, Meleth,
D' Arcy, & Rajput, 1995) revealed that nearly 20% of institutionalized elderly
suffer from some form of tremor (Le., essential tremor, Parkinson's disease,
drug-induced Parkinsonism), and Marti-Masso and Poza (1992) conducted an
epidemiological study that revealed that nearly 7% of the population older than
65 has some form of tremor-type disorder. Another recent study (Jeste, Caligiuri,
Paulsen, Heaton, Lacro, Harris, Bailey, Fell. & McAdams, 1995) revealed that in
a sample of 266 patients receiving treatment with neuroleptics, incidence of
those suffering from tardive dyskinesia doubled in just 3 years. Finally, another
study revealed significant psychosocial effects associated with essential tremor
and physical and psychosocial effects associated with Parkinsonism (Busen-
bark, Nash, Nash, Hobble, & Keller. 1991). Thus. tremors are relatively common
among older adults and, when present. may result in significant physical and
psychosocial difficulties.
In an effort to help ameliorate tremors, some investigators have developed
treatment programs based on behavioral medicine applications. One group of
investigators has incorporated relaxation training and coping skills training into
a biobehavioral rehabilitation treatment program for tremors (Chung, Poppen, &
Lundervold, 1995; Lundervold & Poppen, 1995). As part of the program, sub-
jects also undergo a medical and neurologic assessment as well as a functional
analysis of behavior. In addition to relaxation and coping skills training, par-
ticipants receive education regarding neuromuscular functioning. In one of the
studies (Chung et aI, 1995) the investigators reported results for two older men
(ages 63 and 86), with outcome measures including tremor severity ratings
(both clinical and self-rated), ratings from informants, and forearm EMG. Re-
sults indicated improvements on all of these measures. Given that the most
common tremors occur in the arms and hands (Zimmerman, Deuschl, Hornig,
Schulze-Mouting, Fuchs, & Lucking, 1994), it make sense to utilize a measure of
arm muscle tension (i.e., forearm EMG). In another examination of treatment for
tremors, results from a case study of a 76-year-old man who treated his Parkin-
sonian tremors with self-hypnosis revealed that this technique may have some
potential (Wain, Amen, & Jabbari, 1990).
Despite the early success and hopeful findings from these two studies, sig-
nificant work remains before we can recognize behavioral medicine interventions
as effective in the treatment of tremors. Some issues for future investigation in-
clude replication of the studies and use of appropriate control groups. The issue
of psychogenic tremors (Koller, Lang, Vetere-Overfield, Cleeves, Factor, Singe, &
Weiner, 1989) also remains an area for future investigation. Finally, there is the
question of how these types of treatment programs compare with medication and
how a combined protocol might work.
Falls
Falls are a major problem among older adults. With the older adult popu-
lation growing rapidly in the United States, this is likely to become an area of
ever greater importance. This is especially true because the old-old group (over
80 years of age) is among the fastest growing segments of the population, and
balance problems are one of the main factors that distinguishes the old-old
group from those in the younger (65 to 75) age range (Kaye, Oken, Howieson,
Howieson, Holm, & Dennison, 1994).
A thorough review of the literature on falls among older adults is not pos-
sible. Interested readers may wish to refer to an excellent article by Steinmetz
and Hobson (1994), which details issues related to falls among older adults liv-
ing in the community. Some of the research conducted on balance and falls has
attempted to ascertain what defect is responsible for the problem. Some recent
information suggests that falls among older adults may be due to decreased sen-
sitivity of tactile information from the toes (Tanaka, Hashimoto, Noriyasu, Ina,
Itokube, & Mizumoto, 1995). This is consistent with much ofthe other evidence
that points to the importance of involvement of the kinesthetic system and ne-
cessity of proprioceptic information in balance among older adults (Bergin,
Bronstein, Murray, Sancoric, & Zeppenfeld, 1995; Elliot, Patta, Flanagan,
Spaulding, Rietdyk, Strong, & Brown, 1995).
Another important etiological factor in falls among older adults involves
pharmacologic treatments (Monfort, 1995). This is especially problematic
among older adults because health care professionals may fail to recognize falls
as a side effect of medication but may instead interpret falls as additional evi-
dence of declining mobility. Several medications may produce falls as a side ef-
fect. Of significance to mental health professionals is a recent study by Liu,
Topper, Reeves, Gryfe, & Maki (1995), which revealed that use of antidepressant
medications has predictive value in determining who falls. Other medications
implicated in producing falls as one side effect among older adults include
clozapine (Pitner, Mintzner, Pennypacker, & Jackson, 1995), clomipramine (Leo
& Kim, 1995), and benzodiazepines (Cooper, 1994). The study by Cooper also
revealed that longer-acting benzodiazepines produce more falls among older
adults than do shorter-acting benzodiazepines.
Attempts have also proceeded to identify other risk factors associated with
falls. One recent study (Tinetti, Doucette, Claus, & Marottoli, 1995) identified
several factors associated with what the authors defined as serious fall injuries;
the risk factors identified in this study included cognitive impairment, female
gender, and low body mass index. Balance and gait disturbances, as one would
expect, were also significant risk factors. Another study identified age, psy-
choactive drug use, and number of illnesses as primary predictors of falls
among older adults (Sheahan, Coons, Robbins, Martin, Hendricks, & Latimer,
1995). However, in Sheahan and colleagues' study, frequency of alcohol use and
living alone did not serve as good predictors of falls. In addition, unlike Tinetti
and colleagues' study, gender had no predictive value. Other research (Nelson
et al., 1994) has implicated smoking as another predictor of poor balance.
An interesting study by Salgado, Lord, Packer, and Ehrlich (1994) attempted
to identify predictors to classify fallers from nonfallers among older hospitalized
adults. These authors obtained impressive results, correctly classifying 80% of
their subjects. Variables that contributed to this classification included impaired
orientation, psychoactive medication use, evidence of prior cerebrovascular ac-
cident, and poor scores on a test called the get-up-and-go test.
From these studies, it is clear that many studies have identified cognitive
impairment as a significant predictor of falls among older adults; some of the
studies identify inability to avoid obstacles that are in the intended path as one
of the significant problems. With regard to this latter concern, one recent study
(Persad, Giordani, Chen, Aston-Milles, Alexander, Wilson, Berent, Guire, &
Schultz, 1995) attempted to assess neuropsychological variables associated
with deficits in avoidance ability. This study revealed that measures of memory
and visuo-spatial discrimination were not helpful in predicting avoidance
deficits among older adults. Measures that did predict avoidance difficulties in-
volved problem-solving abilities, general anxiety, assessment of response inhi-
bition, and evaluation of sustained attention.
Given the large amount of data that implicates cognitive impairment in
falls, one would suspect that patients who suffer from neurological disorders
are likely to have difficulties with falling. Recent research shows this to be true
for both patient's with Alzheimer's disease and patients who have suffered from
cerebrovascular accidents. A recent study by Alexander, Mollo, Giordani, Ash-
ton-Miller, Schultz, Grunawalt, & Foster, (1995) indicated that the problem with
falling among Alzheimer's patients is likely due to balance difficulties in new
situations and in situations where obstacles are blocking their intended paths.
Interestingly, in this study, patients with Alzheimer's were able to maintain bal-
ance in situations that were essentially similar, but they walked significantly
more slowly than one might consider normal. As for falls related to cerebrovas-
cular accidents, it appears to depend upon the site of the cerebrovascular acci-
dent. For example, patients with hemispatial deficits, as measured by the
Complex Figure Test or Letter Cancellation Test, may evidence some difficulties
falling (Rapport, Dutra, Webster, & Charter, 1995).
One of the main problems associated with falling is, of course, the potential
for harm. Another problem is that approximately 25% of patients who experi-
ence a fall sufficient for admission to a hospital indicate a fear of falling again
(Liddle & Gilleard, 1995). This fear may lead to decreased walking and subse-
quently decreased independence, as they restrict their activities in an unneces-
sary preventative effort. However, the Liddles and Gilleard study indicated that
the fear of falling appears to have little or no effect on outcome of patients' re-
habilitation efforts. Recurrent falls, nonetheless, do affect life satisfaction (Ho et
a1., 1995), and even one fall can affect patients' confidence in their ability to
arise from a fall. This is an important factor because such confidence relates to
patients' willingness to learn how to arise from falls (Simpson & Mandelstam,
1995). One factor that appears related to fear of falling among older adults is
dizziness (Burker, Wong, Sloane, Mattingly, Preister, & Mitchell, 1995).
Clinical investigators have attempted to devise programs to help people
who fall and to help prevent falls. Treatment programs aimed at increasing mo-
bility have yielded positive results. One recent study showed that a low-inten-
sity 6-week exercise program was successful in decreasing amount of time and
number of steps the older adults in this study used to traverse a measured
course, and that patients who continued to participate in regular exercise were
able to maintain their gains at an 18-week follow-up (Hickey, Wolf, Robins, &
Wagner, 1995). In addition, as is consistent with similar literature, the exercise
program led to improved optimism as measured at the 18-week follow-up. In
another recent study, Lord, Ward, Williams, and Strudwick (1995) evaluated ef-
ficacy of a 12-month program of twice weekly, hour-long exercise sessions on a
variety of measures. Results from this study indicated that subjects who partic-
ipated in the exercise program evidenced improved neuromuscular control, in-
creased lower limb muscle strength, and decreased reaction time. A control
group that did not participate in the exercise program did not evidence these
changes. The main problem with this type of study is that adherence to exercise
programs over a 12-month period of time is generally quite low.
In an effort to address this issue, one set of investigators utilized a video-
taped modeling paradigm to improve exercise performance among five women
aged 56 to 70, who also suffered from mental retardation (Neef, Bill-Harvey,
Shade, Iezzi, & DeLorenzo, 1995). Subjects would utilize the videotape to guide
performance of the exercises, thereby enabling the subjects to perform exercises
independently. Results from this study indicated high levels of independent ex-
ercise with noted improvements in balance. Also of importance, however. is that
several studies have noted the importance of continued social activity and sup-
port as well as continued physical activity in the prevention of falls among older
adults (Cwikel, Fried, Galinsky, & Ring, 1995; Seeman, Berkman, Charpeutier,
Blazer, Albert, & Tinetti, 1995).
Adherence
Because older adults are more likely than younger adults to develop many
chronic conditions that require long-term treatment, there is a definite need to de-
velop methods that will improve adherence among older adults. The treatment
regimen of older adults is likely to be more complicated than that of younger
adults because older adults are likely to have more medications prescribed than
younger adults. When patients have multiple medications to take along with fi-
nite resources (e.g., money) to obtain the prescriptions, nonadherance is likely to
occur. Nonadherence to medication treatment can occur in many forms, includ-
ing decreasing frequency of prescribed dosage to make a prescription last longer
than intended by the physician or failing to get prescriptions filled or refilled.
However, even when resources are scarce, patients often find ways to obtain pre-
scribed medications, such as via borrowed money, pharmacy credit, and physi-
cian samples (Chubon, Schulz, Lingler, & Foster-Schulz, 1994). Unfortunately,

older adults inappropriately discontinue prescription use for as many as 40% of
prescribing situations (Salzman, 1995). One major problem with this is that such
a discontinuation may itself lead to complications and even death. In addition to
decreased use or none use of medication, nonadherence includes overuse and
abuse, as well as medication other than for the intended use, or by a person other
than the one for whom the physician prescribed the medication.
Unfortunately, as with younger adults, education alone as to importance of
adhering to treatments and avoiding risks does not typically change older
adults' behaviors (EI-Faizy & Reinsch, 1994; Herman. Speroff. & Cebul, 1994).
As with younger adults, however, physicians do playa significant role in pa-
tient adherence among older adults. A recent study by Bula, Afessi, Aronow,
Yubas, Gold, Niesenbaum, Beck, & Rubenstein (1995) revealed a correlation be-
tween physician cooperation with a Health Promotion Program for older adults
and patient adherence to recommendations from the program. This is consis-
tent with data that show that among older adults, authoritarian beliefs relate to
utilization of health care services (Ditto, Moore, Hilton, & Kalish, 1995). Thus,
one way to improve adherence may involve improving phy&ician-patient com- (
munications (Salzman, 1995). Weinberger. Samsa, Schmader. & Greenberg
(1994) found that in an outpatient geriatric sample with substantial limitations
in the areas of activities of daily living, patients adhered to only 67% of the rec-
ommendations made. Number ofrecommendations made was 5.9 per patient,
which may represent part of the problem. Patients may have felt overwhelmed
by number of issues to address and may therefore have attended only to the
most salient recommendations. Interestingly, the authors noted that patient ad-
herence to medical and social recommendations was similar, and no predictors
of adherence were found. Consistent with results from this study are those from
a study by Chub on and colleagues (1994), in which the researchers interviewed
subjects on Medicaid who had more than the three prescriptions per month that
needed to be filled. These authors found that patients made their choices based
primarily on three factors: (1) what they believed to be the most important med-
ications or the seriousness of the problem for which they had the prescription,
(2) symptoms that were present at the time, and (3) cost of the medication.
Thus, both the Weinberger and colleagues (1994) and Chub on and colleagues
(1994) studies indicate that older patients often make decisions about their own
care after having received recommendations from their physicians. The deci-
sions they make may not be in their best interest, and one wonders whether
these patients ever inform their health care provider of such decisions.
Provision of health care services may improve if physicians and other
health care providers take additional time to understand their patients' circum-
stances and aid in the decision-making process. Patients who disagree with
treatment recommendations are unlikely tQ adhere to those recommendations
(Devor, Wang, Renvall, Feigal, & Ramsdell, 1994). Unfortunately, the current
health care climate makes longer time for appointments with physicians un-
likely at present (Goreczny & O'Halloran, 1995).
Salzman (1995) did note, however, that in addition to improving physi-
cian-patient communication, another method of improving medication adher-
ence among older adults is to simplify drug treatment regimens, especially
complex regimens that include multiple medications. In such cases, involving
pharmacists as consultants may increase patients' knowledge about their med-

ications and also increase adherence. Lipton and Bird (1994) found that this
was indeed the case in their sample of 706 hospitalized older adults. The in-
vestigators also noted that consultation with pharmacists resulted in patients'
being able to take fewer medications and be on less complex regimens than a
sample of control patients.
An obvious but often forgotten concern is to take into account patients'
medical problems as a possible reason for nonadherence. A study by Nussbaum,
Allender, and Copeland (1995) found that adults with compromised cardiovas-
cular functioning evidenced significant difficulties learning verbal material.
Thus, the well-documented increase in cardiovascular problems associated with
aging increases likelihood that older adults will have problems understanding
and remembering medication instructions. This seems especially likely for
adults with medical difficulties that might further compromise the cardiovascu-
lar system, and these would be the patients most in need of the ability to learn
and remember complex medication regimens. A recent study by Fitten, Cole-
man, Siembieda, Yu, & Ganzell (1995) confirms that older adults with medical
problems have difficulties learning or remembering medication regimens. Con-
sistent with this is a study by Ensrud and colleagues (1994) that evaluated cog-
nitive functioning of older, non-Black women and found that deterioration in
cognitive functioning appears related to several medical conditions.
A recent study compared various methods of improving memory for med-
ication schedules among older adults (D. G. Morrow, Leirer, & Andrassy, 1996).
In this study, the authors asserted that use of a timeline icon may prove helpful
but would require training. Older adults in this study were better able to un-
derstand and remember schedules provided to them via text than via icons. An-
other study investigating improvement of medication adherence among older
adults found that older adults prefer lists of medications as compared to para-
graph instructions (D. Morrow, Leirer, & Altieri, 1995). Patients expressed pref-
erence for a categorized list but were better able to recall information from a
simple listing than from a categorized listing.
Treatment adherence applies not only to medication but also to other ther-
apeutic regimens, and adherence to treatments varies based on type of recom-
mendation made. For example, Devor and colleagues (1994) noted that older
adult outpatients were most likely to adhere to recommendations regarding
prior health directives (81 % adherence), but least likely to comply with recom-
mendations to make changes in living situations (37%); surprisingly, only
57.5% of patients adhered to recommendations to wear a medic alert bracelet.
Also, when patients have choices between two different procedures to correct
for the same problem, age differences often influence that choice (Liddell, Pol-
lett, & MacKenzie, 1995).
A patient factor that health care providers must consider when working
with older adults is onset of dementia. At the beginning of a dementia, signs of
cognitive difficulties may be subtle and unrecognizable by the patient, family
members, and even health care providers. Poor insight into presence of such dif-
ficulties and compromised reasoning abilities associated with dementia may de-
crease adherence (Rees, Bayer, & Phillips, 1995). Depression may also decrease
adherence to treatment protocols (Carney, Freedland, Eisen, Rich, & Jaffe, 1995).
Because depression rates are likely to increase over the years, it is especially im-
portant to develop mechanisms to improve adherence to depression treatments.

For example, Reynolds, Frank, Perel, Mazumdar, & Kupfer (1995) note that a ma-
jor challenge for treating depression among older adults includes compliance
with recommendations. In addition, Schneider and Olin (1995) found that ar-
ranging for a regular evaluation of the client's compliance with recommenda-
tions is one necessary component in effectively treating depression in older
adults. Fortunately, when primary care physicians suggest use of cognitive-be-
havioral techniques to patients suffering from depression, likelihood of adhering
to use of those techniques increased. However, physicians tend to suggest use of
cognitive-behavioral techniques to older adults less than they do to younger
adults (P. Robinson, Bush, Von Koroff, Katon, Lin, Simon, & Walker, 1995).
Another patient factor that health care providers must consider involves
cultural traditions and expectations (Natow, 1994; Parry, Mobley, & Allen,
1996), in addition to issues of personal preference. For example, Cameron and
Quine (1994), in their study of older women who could have benefited from use
of external hip protectors, noted that primary reasons for not wearing these de-
vices were discomfort. These older women believed that the device was not
necessary because they did not perceive that they had a high-risk condition that
would warrant use of the device. The researchers also noted other factors asso-
ciated with lack of adherence, but these were not as prominent as the two just
mentioned. Nonetheless, by identifying patient-perceived impediments to spe-
cific treatments, it may be possible to increase adherence to those treatments.
Another factor associated with nonadherence may be time of day. Leirer, Tanke,
and Morrow (1994) found that adherence tends to be higher in the morning
than at midday, with no further decrement beyond midday.
Efforts to increase adherence have extended beyond that of medication reg-
imen. For example, King, Ross, Seag, & Balshem (1995) attempted to increase
mammography rates of women who had failed to obtain a mammogram within
the year prior to the study. The authors found that telephone counseling about
mammography improved adherence rates from 13% for a control group to 27%
for the counseling group. In addition to counseling, the authors noted that fac-
tors that significantly correlated with adherence to obtaining mammography in-
cluded prior mammography use, ability to access the mammography equipment
or placement easily, and whether or not the person had a friend or relative who
had breast cancer. Additionally, the authors noted that specific beliefs about
breast cancer and mammography significantly predicted mammography use.
Adherence to exercise programs is essential (Dubert & Stetson, 1995). In ad-
dition to playing a significant health promotion role, exercise also serves an im-
portant rehabilitative role among patients with chronic obstructive pulmonary
disease (Carter & Nicotra, 1996). The factors that contribute to exercise adher-
ence among the elderly may be different from those for younger adults. In an ef-
fort to assess factors associated with adherence among older adults, Williams
and Lord (1995) evaluated many variables among 102 older women, 69 of
whom completed a 12-month exercise trial and 54 of whom continued their
participation for at least 6 months after completion of the program. The authors
found that there was a difference between the factors that predicted exercise ad-
herence during training and factors associated with continued participation af-
ter completion of the training. Muscle strength was a factor in adherence to both
measures, but reaction time and psychoactive drug use were significant factors
only for adherence during the trial. Conversely. the only factors associated with
adherence after completion of the trial included reasoning ability. depression.
and a subject's own rating of strength improvement. Thus, physiological factors
appear to playa substantial role in short-term adherence, but longer-term ad-
herence also involves presence and degree of depression and self-perceptions
of program efficacy in producing desired or expected changes.
Finally, in addition to assessments and interventions occurring at the level
of patient interaction, interventions can occur at the multidisciplinary treat-
ment team or organizational level. Although few studies have specifically eval-
uated such interventions with teams that primarily treat older adults, one study
that did so showed that administrative interventions may indeed have an im-
pact on adherence (Wright, Lunt, Harris, & Wallace, 1995). For more informa-
tion on how to implement administrative interventions, see Corrigan and
McCracken (1997).
Other Areas
Another area for investigation is work with older spinal cord injury sur-
vivors. Although the number of people who sustain spinal cord injuries result-
ing in permanent disability is relatively low, technological and medical care
advances in the past two decades have substantially decreased morbidity and
mortality rates in this group (Heinemann, 1995). Thus, number of spinal cord
injury survivors is likely to continue to increase. and combined with the aging
population. this suggests that the number of older adults who have a permanent
disability due to spinal cord injury will also increase. This is especially impor-
tant because of research that indicates that age is one factor related to health
complications and cognitive difficulties among patients with spinal cord in-
juries (Herrick. Elliot, & Crow, 1994). Herrick and colleagues also noted that in-
creased age was related to decreased adherence to routine follow-up health care
in this population. Although this study included no subjects over the age of 66.
the implications for adults over age 66 are clear. It is also clear that there is a
need for study of older adults who have suffered from spinal cord injuries.
Health care providers also need to be aware that unexplained symptoms
may be indicative of systemic lupus erythematosus. A recent paper (M. Dennis,
1994) indicated that systemic lupus erythematosus (SLE) may actually be more
common among older adults than previous research had indicated. In an earlier
paper, M. S. Dennis. Byrne, Hopkinson. and Bendall (1992) reported on five
patients ranging in ages from 75 to 93 who all presented with symptoms later
diagnosed as lupus.
SUMMARY
The current chapter reviewed several areas within the field of health psy-
chology and behavioral medicine as they applied specifically to older adults.
Although research in the area of health psychology with older adults has gen-
erally, lagged behind other research the last few years have witnessed increased
attention to this population. Despite the advances in recent years. much work
remains. For instance, there is relatively little work with helping to meet the so-
cial needs of older, visually impaired adults (Hersen, Van Hasselt, & Segal,
1995), yet this population is a growing exponentially.
Future studies must begin to examine psychometric properties of instru-
ments administered to older adults. Most of the test instruments developed for
clinical use in psychology have only limited data on their applicability to older
adults because the standardization and norms do not adequately apply to older
adults. Recent studies have attempted to correct this problem (e.g., Hersen, Van
Hasselt, & Segal, 1995; Laatsch, 1996), but much work remains in this area.
There exist very few treatment studies on older adults with regard to be-
havioral medicine interventions. Also, there is still a need to investigate the dif-
ferential effects of medication on younger and older adults. This is especially
true for the old-old population. Medications may have differential effects due to
decreasing body functioning, differential rates of adherence, or a variety of
other factors (Andersson, Antonsson, Corin, Swahn, & Fridlund, 1995). Addi-
tional research into factors affecting adherence is also necessary. For example,
too many recommendations from health care providers may result in patients
ignoring some of the recommendations and choosing on their own which to im-
plement. Research will also need to further determine the effect of cognitive dif-
ficulties on adherence. Research into health beliefs among older adults may
also prove to be helpful in improving adherence. The Cognitive Orientation
Model (Kreitler & Kreitler, in press) may prove helpful in this regard. In the area
of cognitive impairment, some recent studies have begun showing that cogni-
tive retraining for patients with dementias may prove helpful. Programs that
seem to have the most benefit, however, are those that have focused on implicit
memory skills as opposed to explicit memory skills (Ford, 1996); this presents
a potentially very fruitful area of clinical research. Exercise also appears to have
some benefit on cognitive functioning (Van Sickle, Hersen, Simco, Melton, &
Van Hasselt, 1996).
Thus, the area of older adult health psychology is a burgeoning field. In
more ways than other fields, it brings together the full continuum of health care
providers, both for prevention and rehabilitation. The range of health problems
experienced by older adults and the sheer number of problems they experience
along with the growing proportion of this segment of the population makes this
a promising arena for future research.
REFERENCES
Abraham. S .• Llewellyn-Jones. D.• & Perz. J. (1994). Changes in Australian women's perception of
the menopause and menopausal symptoms before and after the climacteric. Maturitas. 20.
121-128.
Adamchak. D. J.• Wilson. A.D .• Nyanguru. A.• & Hampson. J. (1991). Elderly support and intergen-
erational transfer in Zimbabwe: An analysis by gender. marital status. and place of residence.
Gerontologist. 31. 505-513.
Alexander. N. B.. Mollo. J. M.• Giordani. B.• Ashton-Miller. J. A.• Schultz. A. B.• Grunawalt. J. A.. &
Foster. N. L. (1995). Maintenance of balance. gait patterns. and obstacle clearance in
Alzheimer's disease. Neurology. 45. 908-914.
Andersson. E.. Antonsson. M.• Corin. B.• Swahn. B.• & Fridlund. B. (1995). The preventive effect of
lithium therapy on bipolar disorder patients. with special reference to gender and age. Inter-
national Journal of Rehabilitation and Health. 1. 203-210.
Arbuckle, N. w., & de Vries, B. (1995). The long-term effects oflater life spousal and parental be-
reavement on personal functioning. Gerontologist, 35, 637-647.
Barker, J. C., Mitteness, L. S., & Wolfsen, C. R. (1994). Smoking and adulthood: Risky business in a
nursing home. Journal of Aging Studies, 8, 309-326.
Beats, B., Burns, A., & Levy, R. (1991). Single photon emission tomography in dementia. Interna-
tional Journal of Geriatric Psychiatry. 6, 57-62.
Beekman, A. T. F., Deeg, D. J., van Tilburg, T., Smit, J. H., Hooijer, C., & van Tilburg, W. (1995). Ma-
jor and minor depression in later life: A study of prevalence and risk factors. Journal of Affec-
tive Disorders, 36, 65-75.
Benjamin, A. E. (1988). Long-term care and AIDS: Perspectives from experience with the elderly.
Milbank Quarterly, 66,415-443.
Bergin, P. S., Bronstein, A. M., Murray, N. M., Sancovic, S., & Zeppenfeld, D. K. (1995). Body sway
and vibration perception thresholds in normal aging and in patients with polyneuropathy.
Journal of Neurology, Neurosurgery. and Psychiatry, 58, 335-340.
Bosse, R., Garvey, A. J., & Costa, P. T. (1980). Predictors of weight change following smoking cessa-
tion. International Journal of the Addictions, 15,969-991.
Bosse, R., Sparrow, D., Garrey, A. J., Costa, P. T., Jr., Weiss, S. T., & Rowe, J. W. (1980). Cigarette
smoking, aging, and decline in pulmonary function: A longitudinal study. Archives of Envi-
ronmental Health, 35, 247-252.
Brackstone, M. J., Delehanty, R., Mann, B., & Pain, K. (1995). The nature and severity of distress
among rehabilitation hospital patients. International Journal of Rehabilitation and Health, 1,
37-48.
Brantley, P. J., & Thomason, B. T. (1995). Stress and stress management. In A. J. Goreczny (Ed.),
Handbook of health and rehabilitation psychology (pp. 275-289). New York: Plenum.
Bula, C., Alessi, C. A., Aronow, H. V., Yubas, K., Gold, M., Niesenbaum, R. Beck, J. C., & Rubenstein,
L. Z. (1995). Community physicians' cooperation with a program of in-home comprehensive
geriatric assessment. Journal of the American Geriatrics Society. 43, 1016-1020.
Burker, E. J., Wong, H., Sloane, P. D., Mattingly, D., Preisser, J., & Mitchell, C. M. (1995). Predictors
offear offalling in dizzy and nondizzy elderly. Psychology and Aging, 10, 104-110.
Burton, L. C. Paglia, M. J. German, P. S., Shapiro, S., & Damiano, A. M. (1995). The effect among
older persons of general preventive visit on three behaviors: Smoking, excessive alcohol
drinking, and sedentary lifestyle. The Medicare Preventive Services Research Team. Preven-
tive Medicine: An International Journal Devoted to Practice and Theory, 24, 492-497.
Busenbark, K. L., Nash, J., Nash, S., Hubble, J. P., & Koller, W. C. (1991). Is essential tremor benign?
Neurology, 41, 1982-1983.
Cameron, I. D., & Quine, S. (1994). External hip protectors: Likely non-compliance among high
risk elderly people living in the community. Archives of Gerontology and Geriatrics. 19.
273-281.
Carmack, C. L., Amaral-Melendez, M., Boudreaux, E.. Brantley. P. J.• Jones. G. N.. Franks. B. D., &
McKnight, G. T. (1995). Exercise as a component of the physical and psychological rehabilita-
tion of hemodialysis patients. Journal of Rehabilitation and Health, 1, 13-24.
Carmelli, D., Dame, A., & Swan, G. E. (1992). Age-related changes in behavioral components in re-
lation to changes in global Type A behavior. Journal of Behavioral Medicine, 15,143-154.
Carney, R. M., Freedland, K. E., Eisen, S. A., Rich, M. W., & Jaffe. A. S. (1995). Major depression and
medication adherence in elderly patients with coronary artery disease. Health Psychology, 14,
88-90.
Carpenter, B. D., Strauss, M. E., & Kennedy, J. S. (1995). Personal history of depression and its ap-
pearance in Alzheimer's disease. International Journal of Geriatric Psychiatry, 10, 669-678.
Carter, R., & Nicotra, B. (1996). The effect of exercise training and rehabilitation on functional sta-
tus in patients with chronic obstructive pulmonary disease (COPD). International Journal of
Rehabilitation and Health, 2,143-167.
Chrischilles, E. A., Lemke, J. H., Wallace, R. B., & Drube, G. A. (1990). Prevalence and characteris-
tics of multiple analgesic drug use in an elderly study group. Journal of the American Geri-
atrics Society. 38, 979-984.
Chubon, S. J., Schulz, R. M., Lingle, E. W., & Coster-Schulz, M. A. (1994). Too many medications,
too little money: How do patients cope? Public Health Nursing, 11,412-415.
Chung. W., Poppen, R.. & Lundervold, D. A. (1995). Behavioral relaxation training for tremor disor-
ders in older adults. Biofeedback and Self-Regulation, 20, 123-135.
Colsher, P. 1., Wallace, R B., Pomrehn, P. R, LaCroix, A. Z., Corn ani-Huntley, J., Blazer, D., Scherr,
P. A. Berkman, L., Hennekens, C. (1990). Demographic and health characteristics of elderly
smokers: Results from established populations for epidemiolgic studies of the elderly. Amer-
ican Journal of Preventive Medicine, 6, 61-70.
Cooper, J. W. (1994). Falls and fractures in nursing home patients receiving psychotropic drugs. In-
ternational Journal of Geriactric Psychiatry, 9, 975-980.
Corrignan, P., & McCracken, S. (1997) Interactive staff training: Rehabilitation teams that work. New
York: Plenum.
Cosford, P., & Arnold, E. (1991). Anorexia nervosa in the elderly. British Journal of Psychiatry, 159,
296-297.
Cosford, P. A., & Arnold, E. (1992). Eating disorders in later life: A review. International Journal of
Geriatric Psychiatry, 7, 491-498.
Cummings, K. M., Kelly, J., Sciandra, R, & DeLoughry, T. (1990). Impact of a community-wide stop
smoking contest. American Journal of Health Promotion, 4, 429-434.
Cwikel, J., Fried, A., Galinsky, D., & Ring, H. (1995). Gait and activity in the elderly: Implications
for community falls-prevention and treatment programmes. Disability and Rehabilitation: An
International Multidisciplinary Journal, 17, 277-280.
Davis, M. A. Neuhaus, J. M., Moritz, D. J., Lein, D., Barclay, J. D., & Murphy, S. P. (1994). Health be-
haviors and survival among middle-aged and older men and women in the NHANES I Epi-
demiological Follow-up Study. Preventive Medicine: An International Journal Devoted to
Practice and Theory, 23, 369-376.
Dekker, P., & Mootz, M. (1992). AIDS as threat, AIDS as stigma: Correlates of AIDS beliefs among the
Dutch general public. Psychology and Health, 6, 347-365.
Dennis, M. (1994). Neuropsychiatric lupus erythematosus and the elderly. International Journal of
Dennis, M. S., Byrne, E. J., Hopkinson, N., & Bendall, P. (1992). Neuropsychiatric systemic lupus
erythematosus in elderly people: A case series. Journal of Neurology, Neurosurgery and Psy-
chiatry, 55, 1157-1161.
Devor, M., Wang, A., Renvall, M., Feigal, D., & Ramsdell, J. (1994). Compliance with social and
safety recommendations in an outpatient comprehensive geriatric assessment program. Jour-
nals of Gerontology, 49, M168-M173.
Ditto, P. H., Moore, K. A., Hilton, J. L., & Kalish, J. R (1995). Beliefs about physicians: Their role in
health care utilization, satisfaction, and compliance. Basic and Applied Social Psychology, 17,
23-48.
Downe-Wambodlt, B. L., & Melanson, P. M. (1995). Emotions, coping, and psychological well-being
in elderly people with arthritis. Western JournaJ of Nursing Research, 17, 250-265.
Duhert, P. M., & Stetson, B. A. (1995). Exercise and physical activity. In A. J. Goreczny (Ed.), Hand-
book of health and rehabilitation psychology (pp. 255-274)' New York: Plenum.
EI-Faizy, M., & Reinsch, S. (1994). Home safety intervention for the prevention offalls. Physical and
Occupational Therapy in Geriatrics, 12, 33-49.
Elliot, D. B., Patla, A. E., Flanagan, J. G., Spaulding, S., Rietdyk, S., Strong, G., & Brown, S. (1995).
The Waterloo vision and mobility study: Postural control strategies in subjects with ARM.
Ophthalmic and Physiological Optics, 15, 553-559.
Ensrud, K. E., Nevitt, M. C., Yunis, C., Cauley, J. A., Seeley, D. G., Fox, K. M., & Cummings, S. R
(1994). Correlates of impaired function in older women. Journal of the American Geriatrics
Society, 42, 481-489.
Fenley, J., Powers, P. S., Miller, J., & Rowland, M. (1990). Untreated anorexia·nervosa. A case study
ofthe medical consequences. General Hospital Psychiatry, 12,264-270.
Fincham, J. E. (1992). The etiology and pathogenesis of detrimental health effects in elderly smok-
ers. Journal of Geriatric Drug Therapy; 7, 5-21.
Fishbein, M. Chan, D. K., O'Reilly, K., & Schnell, D. (1993). Factors influencing gay men's attitudes,
subjective norms, and intentions with respect to performing sexual behaviors. Journal of Ap-
plied Social Psychology, 23, 417-438.
Fitten, 1. J., Coleman, L., Siembieda, D. W., Yu, M., & Ganzell, S. (1995). Assessment of capacity to
comply with medication regimens in older patients. Journal of the American Geriatrics Soci-
ety, 43, 361-367.
Ford, S. (1996). Cognitive rehabilitation of patients with dementia: A review of the effective-
ness of learning mnemonics. International Journal of Rehabilitation and Health, 2,
277-283.
Foster, M. F. (1992). Health promotion and life satisfaction in elderly Black adults. Western Journal
of Nursing Research, 14,444-463.
Friedman, L. Brooks, J. O. 3rd, Bliwise, D. L., Yesavage, J. A.. & Wicks, D.S. (1995). Perceptions of
life stress and chronic insomnia in older adults. Psychology and Aging, 10,352-357.
Glasgow, R K, Stevens, V. J., Vogt, J. M., & Mullooly, J. P. (1991). Changes in smoking associated with
hospitalization: Quit rates, predictive variables, and intervention implications. American Jour-
nal of Health Promotion, 6, 24-29.
Goreczny, A. J. (1995a). Handbook of health and rehabilitation psychology. New York: Plenum.
Goreczny, A. J. (1995b). Introductory statement-Forging ahead into the 21st century: Issues in re-
habilitation. International Journal of Rehabilitation and Health, 1, 1-3.
Goreczny, A. J. (1997). The stress of being a stress researcher. Manuscript submitted for publication.
Goreczny, A. J., & O'Halloran, C. M. (1995). The future of psychology in health care. In A. J. Goreczny
(Ed.), Handbook of health and rehabilitation psychology (pp. 663-676). New York: Plenum.
Goreczny, A. J., Keen, A., & Walter, K (1997). Psychophysiological responding among older versus
younger adults. Manuscript in preparation.
Cosford, P. A., & Arnold, E. (1992). Eating disorders in later life: A review. International Journal of
Gowers, S. G., & Crisp, A. H. (1990). Anorexia nervosa in an 80-year-old woman. British Journal of
Green, B. H., Copeland, J. R, Dewey, M. E., Sharma, V., Saunders, P. A., Davidson, I. A., Sullivan,
C., McWilliam, C. (1992). Risk factors for depression in the elderly: A prospective study. Acta
Psychiatrica Scandinavica, 86, 213-217.
Grembowski, D., Patrick D., Diehr, P., Durham, M., Beresford, S., Kay, E., & Hecht, J. (1993). Self-efficacy
and health behavior among older adults. Journal of Health and Social Behavior, 34, 89--104.
Gutheil, I. A., & Chichin, E. R (1991). AIDS, older people, and social work. Health and Social Work,
16,237-244.
Hall, P., & Driscoll, R (1993). Anorexia in the elderly-an annotation. International Journal of Eat-
ing Disorders, 14,497-499.
Hamm, V. P., Bazargan, M., & Barbre, A. R (1993). Life-style and cardiovascular health among urban
Black elderly. Journal of Applied Gerontology, 12, 155-169.
Hayslip, B., Maloy, R M., & Kohl, R (1995). Long-term efficacy of fluid ability interventions with
older adults. Journals of Gerontology Series B-Psychological Sciences and Social Sciences,
50B, P141-P149.
Heinemann, A. W. (1995). In A. J. Goreczny (Ed.), Handbook of health and rehabilitation psychol-
ogy(pp. 341-360). New York: Plenum.
Helzlsouer, K J., Ford, D. E., Hayward, R S., Midzenski, M., & Perry, H. (1994). Perceived risk of
cancer and practice of cancer prevention behaviors among employees in an oncology center.
Preventive Medicine: An International Journal Devoted to Practice and Theory, 23, 302-308.
Hensrud, D. D., & Sprafka, J. M. (1993). The smoking habits of Minnesota physicians. American
Journal of Public Health, 83,415-417.
Herman, C. J., Speroff, T., & Cebul, RD. (1994). Improving compliance with immunization in the
older adults: Results of a randomized cohort study. Journal of the American Geriatrics Society,
42, 1154-1159.
Herrick, S., Elliot, T. R, & Crow, F. (1994). Social support and the prediction of health complications
among persons with spinal cord injuries. Rehabilitation Psychology, 39, 231-250.
Hersen, M., Van Hasselt, V. B., & Goreczny, A. J. (1993). Behavioral assessment of anxiety in older
adults. Behavior Modification, 17,99--112.
Hersen, M., Kabacoff, R I., Ryan, C. F., Null, J. A., Melton, M. A., Pagan, V., Segal, D. 1., & Van Has-
selt, V. B. (1995). Psychometric properties of the Wolpe-Lazarus Assertiveness Scale for older
visually impaired adults. International Journal of Rehabilitation and Health, 1, 179--188.
Hersen, M., Van Hasselt, V. B., & Segal, D. L. (1995). Social adaptation in older visually impaired
adults: Some comments. International Journal of Rehabilitation and Health, 1,49--60.
Hickey, T., Wolf, F. M., Robins, L. S., & Wagner, M. B. (1995). Physical activity training for func-
tional mobility in older persons. Journal of Applied Gerontology, 14,357-371.
Hinkin, c., Cummings, J. L., Van Gorp, W. G., & Satz, P. (1990). Frontal/subcortical features of nor-
mal aging: An empirical analysis. Canadian Journal on Aging, 9, 104-119.
Ho, S. C., Woo, J., Lau, J., Chan, S. G., Yuen, Y. K., Chan, Y. K, & Chi, I. (1995). Life satisfaction and
associated factors in older Hong Kong Chinese. Journal of the American Geriatrics Society, 43,
252-255.
Hocking, L. B., & Koenig, H. G. (1995). Anxiety in medically ill older patients: A review and update.
International Journal of Psychiatry and Medicine, 25, 221-238.
Huerta, R, Mena, A., Malacara, I.-M., & Diaz-de-Leon, I. (1995). Symptoms at the menopausal and
premenopausal years: Their relationship with insulin, glucose, cortisol, FSH, prolactin, obe-
sity and attitudes towards sexuality. Psychoneuroendocrinology, 20, 851-864.
Itoh, R.. & Suyama, Y. (1995). Sociodemographic factors and life-styles affecting micronutrient sta-
tus in an apparently healthy elderly Japanese population. Journal of Nutrition for the Elderly,
14,39-54.
Jensen, E., Dehlin, 0., Hayberg, B., Samuelsson, G., & Svensson, T. (1994). Medical, psychological, and
sociological aspects of drug treatment in 80-year-olds. Zeitschrijt fUr Gerontologie, 27, 140-144.
Jeste, D. V., Caligiuri. M. P., Paulsen, J. S., Heaton, R K., Lacro, J. P. Harris, M. J., Bailey, A., Fell,
R. 1., & McAdams, L. A. (1995). Risk of tardive dyskinesia in older patients: A prospective
longitudinal study of 266 outpatients. Archives of General Psychiatry. 52, 756--765.
Jones, A., Greaves, K., & Iliffe, S. (1992). Health protective behaviour and knowledge of coronary
heart disease risk factors in a general practice population. Medical Science Research, 20, 71-73.
Kahana, E., Redmond, C., Hill, G. I., & Kercher, K. (1995). The effects of stress, vulnerability, and ap-
praisals on the psychological well-being ofthe elderly. Research on Aging, 17,459-489.
Kaye, J. A., Oken, B. S., Howieson, D. B., Howieson, I., Holm, L. A., & Dennison, K. (1994). Neuro-
logic evaluation ofthe optimally healthy oldest old. Archives of Neurology, 51, 1205-1211.
Kernutt, G. J., Price, A. J., Judd, F. K., & Burrows, G. D. (1993). Human immunodeficiency virus infec-
tion, dementia and the older patient. Australian and New Zealand Journal of Psychiatry, 27, 9-19.
King, E. S., Ross, E., Seay, J., & Balshem, A. (1995). Mammography interventions for 65- to 74-year-
old HMO women: Program effectiveness and predictors of use. Journal of Aging and Health,
7,529-551.
Koller, w., Lang, A.. Vetere-Overfield, B., Findley, L., Cleeves, L., Factor, S., Singer, C., & Weiner, W.
(1989). Psychogenic tremors. Neurology, 39,1094-1099.
Kopac, C. A. (1990). The environment and its relationship to the Type A behavior pattern in middle
and old age: A pilot study. Psychological Reports, 66, 768-770.
Krause, N. (1995a). Assessing stress-buffering effects: A cautionary note. Psychology and Aging, 10,
518-526.
Krause, N. (1995b). Stress, alcohol use, and depressive symptoms in later life. Gerontologist, 35,
296-307.
Krause, N. (1996). Neighborhood deterioration and self-rated health in later life. Psychology and Ag-
ing, 11, 342-352.
Kreitler, S., & Kreitler, H. (1997). Cognitive orientation and health-protective behaviors. Interna-
tional Journal of Rehabilitation and Health, 3, 1-24.
Kviz, F. Crittenden, K. S., Clark, M. A., & Madura, K. J. (1994). Buddy support among older smok-
ers in a smoking cessation programa. Journal of Aging and Health, 6, 229-254.
Kviz, F. J., Clark, M. A., Crittenden, K. S., Warnecke, R B., & Freels, S. (1995). Age and smoking ces-
sation behaviors. Preventive Medicine: An International Journal Devoted to Practice and The-
ory; 24, 297-307.
Laatch, L. (1996). Use of stratified norms for the Mattis Dementia Rating Scale in an urban rehabil-
itation sample. International Journal of Rehabilitation and Health, 2, 199-207.
Landreville, P., Dube, M.. Lalande, G., & Alain, M. (1994). Journal of Social Behavior and Personal-
ity, 9, 269-286.
Lave, I. R, Ives, D. G., Traven, N. D., & KuHer, L. H. (1995). Participation in health promotion pro-
grams by rural elderly. American Journal of Preventive Medicine, 11, 46--53.
Laws, A., King, A. C., Haskell, W. L., & Reaven, G. M. (1993). Metabolic and behavioral covariates
of high-density lipoprotein cholesterol and triglyceride concentrations in postmenopausal
women. Journal of the American Geriatrics Society, 41, 1289-1294.
Lazarus, R. S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lee, C. (1989). Perceptions of immunity to disease in adult smokers. Journal of Behavioral Medi-
cine, 12,267-277.
Lee, S. (1992). The clinical validity oftardive anorexia nervosa. Australian and New Zealand Jour-
nal of Psychiatry, 26, 686--688.
Lefebvre, R C., Cobb, G. D., Goreczny, A. I., & Carleton, R A. (1990). Efficacy of an incentive-based
community smoking cessation program. Addictive Behaviors, 15, 403-411.
Leigh, B. C., Temple, M. T., & Trocki, K F. (1993). The sexual behavior of US adults: Results from a
national survey. American Journal of Public Health. 83, 1400-1408.
Leirer, V. 0., Tanke, E. D., & Morrow. D. G. (1994). Time of day and naturalistic prospective mem-
ory. Experimental Aging Research, 20, 127-134.
Leo, R. J., & Kim. K. Y. (1995). Clomipramine treatment ofparaphilias in elderly demented patients.
Journal of Geriatric Psychiatry and Neurology, 8, 123-124.
Liberto. J. G., & Oslin. D. W. (1995). Early versus late onset of alcoholism in the elderly. Drugs and
the elderly: Use and misuse of drugs. medicines. alcohol. and tobacco [Special issue]. Inter-
national Journal of the Addictions, 30, 1799-1818.
Lichtenstein. E., & Hollis. J. (1992). Patient referral to a smoking cessation program: Who follows
through? Journal of Family Practice. 34. 739-744.
Liddell. A., Pollett. W. G.• & MacKenzie. D. S. (1995). Comparison of postoperative satisfaction be-
tween ulcerative colitis patients who chose to undergo either a pouch or an ileostomy opera-
tion. International Journal of Rehabilitation and Health. 1.89-96.
Liddle. J., & Gilleard, C. (1995). The emotional consequences offalls for older people and their fam-
ilies. Clinical Rehabilitation. 9. 110-114.
Linsk, N. L. (1994). HIV and the elderly. Families in Society, 75. 362-372.
Lipton. H. 1.. & Bird. J. A. (1994). The impact of clinical pharmacists' consultations on geriatric patients'
compliance and medical care use: A randomized controlled trial. Gerontologist. 34. 307-315.
Liu. B. A., Topper, A. K, Reeves. R. A.. Gryfe. C.• & Maki. B. E. (1995). Falls among older people: Re-
lationship to medication use and orthostatic hypotension. Journal of the American Geriatrics
Society. 43, 1141-1145.
Lloyd, G. A. (1989). AIDS & elders: Advocacy, activism. & coalitions. Generations. 13, 32-35.
Lord, S. R.. Ward. J. A.. Williams. Poo & Strudwick, M. (1995). The effect of a 12-month exercise trial
on balance, strength, and falls in older women: A randomized controlled trial. Journal of the
American Geriatrics Society, 43, 1198-1206.
Lundervold. D. A., & Poppen. R. (1995). Biobehavioral rehabilitation for older adults with essential
tremor. Gerontologist, 35, 556-559.
Ma, S. S. Y., & Chi, I. (1995). Health counseling for older people in Hong Kong. Learning to live at
all ages [Special Issue). Educational Gerontology. 21, 515-528.
Malatesta-Magai, C.. Jonas. R.. Shepard, B., & Culver. L. C. (1992). Type A behavior pattern and emo-
tion expression in younger and older adults. Psychology and Aging. 7, 551-561.
Marti-Masso, J. F. & Poza, J. J. (1992). A new type of epidemiological study: Questionnaire adminis-
tered by medical personnel. Neuroepidemiology, 11,296-298.
Martinez, M .• Arnalich, F.• Vazquez, J. J., & Hernanz. A. (1993). Altered cerebrospinal fluid
amino acid pattern in the anorexia of aging: Relationship with biogenic amine metabolism.
Life Sciences. 53, 1643-1650.
Maxwell. C. J., & Hirdes, J. P. (1993). The prevalence of smoking and implications for quality of life
among the community-based elderly. American Journal of Preventive Medicine. 9, 338-345.
Melanson. P. M., & Downe-Wamboldt, B. (1995). The stress of life with rheumatoid arthritis as per-
ceived by older adults. Activities, Adaptation and Aging, 19, 33-47.
Miller, D. K, Morley. J. E., Rubenstein, 1. Zoo & Pietruszka, F. M. (1991). Abnormal eating attitudes
and body image in older undernourished individuals. Journal of the American Geriatrics So-
ciety. 39, 462-466.
Mitrushina. M.,Satz. P., Drebing, C., Van Gorp. w., Mathews. A., Harker. J., & Chervinsky. A. (1994).
The differential pattern of memory deficit in normal aging and dementias of different etiology.
Journal of Clinical Psychology. 50, 246-252.
Moghal. S., Rajput. A. H .. Meleth. R.. D'Arcy, c.. & Rajput. R. (1995). Prevalence of movement dis-
orders in institutionalized elderly. Neuroepidemiology. 14,297-300.
Monfort, J. C. (1995). The difficult elderly patient: Curable hostile depression or personality disor-
der. International Psychogeriatrics, 7 (Suppl.). 95-111.
Morley, J. E. (1993). The strange case of an older woman who was cured by being allowed to refuse
therapy. Journal of American Geriatrics Society. 41, 1012-1013.
Morrow, D.• Leirer. V., & Altieri, P. (1995). List formats to improve medication instructions for older
adults. Educational Gerontology, 21, 151-166.
Morrow. D. G.• Leirer. V. 0., & Andrassy. J. M. (1996). Using icons to convey medication schedule
information. Applied Ergonomics. 27, 267-275.
Nakamura. C. M .• Molgaard. C. A .• Stanford. E. P. Peddecord. K. M .• Morton. D. J.• Lockery. S. A..

Zuniga. M .• & Gardner. L. (1990). A discriminant analysis of severe alcohol consumption
among older persons. Alcohol and Alcoholism. 25. 75-80.
Natow. S. J. (1994). Cross-cultural counseling. Journal of Nutrition for the Elderly. 14. 23-31.
Neef. N. A.. Bill-Harvey. D.• Shade. D.• Iezzi. M.. & DeLorenzo. T. (1995). Exercise participation with
videotaped modeling: Effects on balance and gait in elderly residents of care facilities. Behav-
ior Therapy. 26. 135-151.
Nelson. H. D.• Neritt. M. C.• Scott. J. C.• Stone. K. L.• & Cummings. S. R (1994). Smoking. alcohol.
and neuromuscular and physical function of older women: Journal of the American Medical
Association. 272. 1825-1831.
Nussbaum. P. D.• & Goreczny, A. J. (1995). Self-appraisal of stress level and related psychopathol-
ogy. Journal of Anxiety Disorders, 9, 463-472.
Nussbaum, P. D., Allender, J., & Copeland, J. (1995). Verbal learning in cardiac transplant candi-
dates: A preliminary report. International Journal of Rehabilitation and Health, 1, 5-12.
Oei, T. P. S., Tilley, D., & Gow. K. (1991). Differences in reasons for smoking between younger and
older smokers. Drug and Alcohol Review, 10, 323-329.
O'Hara, P., & Portser, S. A. (1994). A comparison of younger-aged and older-aged women in a be-
havioral self-control smoking program. Patient Education and Counseling. 23. 91-96.
Orleans, C. T., Rimer, B. K.. Cristinzio, S., Keintz, M. K., & Fleisher, L. (1991). A national survey of
older smokers: 'Treatment needs of a growing population. Health Psychology. 10.343-351.
Orrell. M., & Bebbington. P. (1995). Life events and senile dementia. I: Admission. deterioration and
social environment change. Psychological Medicine. 25. 373-386.
Parry, K. K., Mobley, T., & Allen, O. (1996). Use offolk treatments for diabetic plantar ulcers among
African Americans with Type II diabetes. International Journal of Rehabilitation and Health,
2,265-283.
Persad, C. C., Giordani, B., Chen, H. C ..Ashton-Miller, J. A., Alexander, N. B., Wilson, C. S., Berent,
S., Guire. K., & Schultz, A. B. (1995). Neuropsychological predictors of complex obstacle
avoidance in healthy older adults. Journals of Gerontology. Series B-Psychological Sciences
and Social Sciences, 50. P272-P277.
Pickering T. G. (1995). Hypertension. In A. J. Goreczny (Ed.), Handbook of Health and Rehabilita-
tion Psychology. New York: Plenum.
Pierce. J.• Giovino. G.• Hatziandreu. E.. & Shopland. D. (1989). National age and sex differences in
quitting smoking. Journal of Psychoactive Drugs. 21. 293-298.
Piette. J.. Wachtel. T. J.• Mor. V.. & Mayer. K. (1995). The impact of age on the quality of life in per-
sons with HIV infection. Journal of Aging and Health, 7. 163-178.
Pitner. J. K.. Mintzer. J. E.• Pennypacker. L. C.• & Jackson. C. W. (1995). Efficacy and adverse effects
of clozapine in four elderly psychotic patients. Journal of Clinical Psychiatry. 56. 180-185.
Rapport. L. J.• Dutra. R L., Webster. J. S .• & Charter. R (1995). Hemispatial deficits on the Rey-
Osterrieth complex figure drawing. Clinical Neuropsychologist. 9. 169-179.
Rees. J.• Bayer. A.• & Phillips. G. (1995). Assessment and management of the dementing driver. Jour-
nal of Mental Health UK, 4. 165-176.
Reynolds, C. F.• Frank. E.• Perel. J. M.. Mazumdar. S .• & Kupfer. D. J. (1995). Maintenance therapies
for late-life recurrent major depression: Research and review circa 1995. International Psy-
chogeriatrics. 7. 27-39.
Riemann. B. C .• McNally. R. J.• & Meier. A. (1993). Anorexia nervosa in an elderly man. Interna-
tional Journal of Eating Disorders, 14. 501-504.
Rimer. B. K.. Orleans, C.·T., Fleisher, L., & Cristinzio, S. (1994). Does tailoring matter? The impact
of a tailored guide on ratings and short-term smoking-related outcomes for older smokers.
Health Education Research, 9, 69-84.
Robinson, B. E., Walters, L. H., & Skeen, P. (1989). Response of parents to leamingthat their child is
homosexual and concern over AIDS: A national study. Journal of Homosexuality. 18. 59-80.
Robinson, P., Bush, T., Von Korff, M., Katon, W., Lin, E., Simon, G. E., & Walker, E. (1995). Primary
care physician use of cognitive behavioral techniques with depressed patients. Journal of
Family Practice. 40, 352-357.
Rose. M. S., & West, M. (1996). Attachment problems and depressive symptomatology in cardiac re-
habilitation patients. International Journal of Rehabilitation and Health, 2,113-124.
Rosenzweig, R, & Fillit, H. (1992). Probable heterosexual transmission of AIDS in an aged woman.
Journal of the American Geriatrics Society. 40, 1261-1264.
Rossen. E. K.• & Buschmann. M. T. (1995). Mental illness in later life: The neurobiology of depres-
sion. Archives of Psychiatric Nursing. 9. 130-136.
Russell. J.• & Gilbert. M. (1992). Is tardive anorexia a discrete diagnostic entity? Australian and New
Zealand Journal of Psychiatry. 26. 429-435.
Salgado. R.. Lord. S. R.. Packer. J.• & Ehrlich. F. (1994). Factors associated with falling in elderly hos-
pital patients. Gerontology, 40. 325-331.
Salive. M. E.. & Blazer. D. G. (1993). Depression and smoking cessation in older adults: A longitu-
dinal study. Journal of the American Geriatrics Society. 41. 1313-1316.
Salzman. C. (1995). Medication compliance in the elderly. Journal of Clinical Psychiatry. 56. 18-23.
Samuelsson. G .. Hagberg. B.• Dehlin. 0 .. & Lindberg. B. (1994). Medical, social and psychological
factors as predictors of survival: A follow-up from 67 to 87 years of age. Archives of Gerontol-
ogy and Geriatrics. 18. 25--41.
Schneider. L. S .• & Olin. J. T. (1995). Efficacy of acute treatment for geriatric depression. Interna-
tional Psychogeriatrics. 7. 7-25.
Schoenfeld-Smith. K.. Nicassio. P. M.• Radojevic. V.. & Patterson. T. L. (1995). Multiaxial taxonomy
of fibromyalgia syndrome patients. Journal of Clinical Psychology in Medical Settings. 2.
149-166.
Schwirian. P. M. (1991-1992). The Seniors' Life-style Inventory: Assessing health behaviors in older
adults. Behavior. Health. and Aging. 2. 43-55.
Scura. K. W.• & Whipple. B. (1990). Older adults as an HIV-positive risk group. Journal of Geronto-
logical Nursing. 16.6-10.
Seeman. T. E.. Berkman. L. F.. Charpentier. P. A .. Blazer. D. G.. Albert. M. S .. & Tinetti. M. E. (1995).
Behavioral and psychosocial predictors of physical performance: MacArthur studies of suc-
cessful aging. Journals of Gerontology. Series A-Biological Sciences and Medical Sciences.
50. Ml77-M183.
Sheahan. S. L.• Coons. S. J.• Robbins. C. A .• Martin. S. S .• Hendricks. J.• & Latimer. M. (1995). Psy-
choactive medication. alcohol use. and falls among older adults. Journal of Behavioral Medi-
cine, 18, 127-140.
Shillington. A. M.• CottIer. L. B.• Compton. W. M .• & Spitznagel. E. L. (1995). Is there a relationship
between "heavy drinking" and HIV high risk sexual behaviors among general population sub-
jects? International Journal of the Addictions, 30. 1453-1478.
Simpson. J. M .• & Mandelstam. H. (1995). Elderly people at risk of falling: Do they want to be
taught how to get up again? Clinical Rehabilitation, 9. 65-69.
Smith. T. W. (1995). Assessment and modification of coronary-prone behavior: A transactional
view of the person in social context. In A. J. Goreczny (Ed.). Handbook of Health and Re-
habilitation Psychology. New York: Plenum.
Steinmetz. H. M .• & Hobson. S. J. G. (1994). Prevention offalls among the community-dwelling
elderly: An overview. Physical and Occupational Therapy in Geriatrics, 12, 13-29.
Suyama. Y. & Itoh. R. (1992). Multivariatc analysis of dietary habits in 931 elderly Japanese
males: Smoking. food frequency and food preference. Journal of Nutrition for the Elderly.
12,1-12.
Swan. G. E.. Dame. A.. & Carmelli. D. (1991). Involuntary retirement. Type A behavior. and current
functioning in elderly men: 27-year follow-up ofthe Western Collaborative Group Study. Psy-
Talashek. M. L.. Tichy. A. M .• & Epping. H. (1990). Sexually transmitted diseases in the elderly: Is-
sues and recommendations. Journal of Gerontological Nursing. 16.33--40.
Talbert. F. S .. Wagner. P. J.• Braswell. L. C .. & Husein. S. (1995). Analysis of long-term stress reac-
tions in emergency room patients: An initial study. Journal of Clinical Psychology in Medical
Settings, 2. 133-148.
Tanaka. T.. Hashimoto. N .• Noriyasu. S .• Ino. S .• lfukube. T.• & Mizumoto. Z. (1995). Aging and pos-
tural stability: Change in sensorimotor function. Physical and Occupational Therapy in Geri-
atrics, 13, 1-16.
Taplin. S. H .• Anderman. C.• Grothaus. L.. Curry. S .. & Montano. D. (1994). Using physician corre-
spondence and postcard reminders to promote mammography use. American Journal of Pub-
lic Health, 84, 571-574.
Tinetti. M. E.. Doucette. J.. Claus. E.. & Marottoli. R. (1995). Risk factors for serious injury during
falls by older persons in the community. Journal of the American Geriatrics SOCiety. 43.
1214-1221.
Tuthill. S. B. (1989). Physical and social factors affecting hypertension. Journal of Human Behav-
ior and Learning. 6, 1-10.
Van Gorp. W. G.. Wilfred. G.. Mitrushina. M.. Cummings. J. L.. & Satz. P. (1989). Normal aging and the
subcortical encephalopathy of AIDS: A neuropsychological comparison. Neuropsychiatry, Neu-
ropsychology, and Behavioral Neurology, 2, 5-20.
Van Gorp. W. G.• Miller. E. N.• Marcotte. T. D.• Dixon. w.. Paz. D.• Seines. 0 .. Wesch. J.• Becker. J. T..
Hinkin. C.D. & Mitrushina. M. (1994). The relationship between age and cognitive impairment
in HIV-I infection: Findings from the Multicenter AIDS Cohort Study and a clinical cohort.
Neurology, 44, 929-935.
Van Sickle. T. D.. Hersen. M.• Simco. E. R.. Melton. M. A.• & Van Hasselt. V. B. (1996). Effects of
physical exercise on cognitive functioning in the elderly. International Journal of Rehabilita-
tion and Health. 2,67-100.
Vella. S .• Giuliano. M.• Floridia. M. Chiesi. A.. Tomino. C.. Seeber. A.. Barcherini, S .• Bucciardini.
R.. & Mariotti, S. (1995). Effect of sex. age and transmission category on the progression to
AIDS and survival of zidovudine-treated symptomatic patients. AIDS, 9, 51-56.
Vermeulen. A. (1994). Clinical problems in reproductive neuroendocrinology of men. Neurobiology
of Aging, 15,489-493.
Vincke. J.. & Bolton. R. (1994). Social support. depression. and self-acceptance among gay men.
Human Relations, 47, 1049-1062.
Vincke. J.• Mak. R.. Bolton. R.. & Jurica. P. (1993). Factors affecting AIDS-related sexual behavior
change among Flemish gay men. Human Organization. 52, 260-268.
Vitaliano. P. P.. Russo. J.• Bailey. S. 1.. Young. H. M.. & McCann. B. S. (1993). Psychosocial factors as-
sociated with cardiovascular reactivity in older adults. Psychosomatic Medicine, 55. 164-177.
Vitaliano. P. P.. Russo. J.. & Niaura, R. (1995). Plasma lipids and their relationships with psychoso-
cial factors in older adults. Journals of Gerontology Series B Psychological Sciences and So-
cial Sciences, SOB, P18-P24.
Wain. H. J.. Amen, D., & Jabbari, B. (1990). The effects of hypnosis on a Parkinsonian tremor: Case
report with polygraph/EEG recordings. American Journal of Clinical Hypnosis, 33, 94-98.
Wei, H., Young. D.. Lingiang, L.. Shuiyuan. X.. Jian. T.. Hanshu. S .. Zhunghong. Y., Xiouying.
Xudong, W. (1995). Psychoactive substance use in three sites in China: Gender differences and
related factors. Addiction, 90,1503-1515.
Weinberger. M., Samsa. G. P., Schmader. K.. & Greenberg. S. M. (1994). Compliance with recom-
mendations from an outpatient geriatric consultation team. Journal of Applied Gerontology,
13,455-467.
Whipple, B., & Scura, K. W. (1989). HIV and the older adult: Taking the necessary precautions. Jour-
nal of Gerontological Nursing, 15, 15-19.
Wiederman, M. W.. Weis, D. L., & Allgeier. E. R. (1994). The effect of question preface on response
rates to a telephone survey of sexual experience. Archives of Sexual Behavior, 23, 203-215.
Williams, P.. & Lord. S. R. (1995). Predictors of adherence to a structured exercise program for older
women. Psychology and Aging, 10,617-624.
Wright, B. D., Lunt. B.. Harris, S. J.. & Wallace, D. (1995). A prospective study in three psychogeri-
atric day hospitals using administrative interventions to improve non-attendance. Interna-
tional Journal of Geriatric Psychiatry, 10, 55-61.
Zaimov, K. A.. Fertcheva, A., & Vanev, P. I. (1994). Motives of smoking and inborn behavioral pre-
program of the personality. International Journal of the Addictions, 29, 957-970.
Zimmermann, R.. Deuschl, G., Hornig, A.. Schulte-Monting, J.; Fuchs, G., & Lucking, C. H. (1994).
Tremors in Parkinson's disease: Symptom analysis and rating. Clinical Neuropharmacology,
17, 303-314.
Zipp, A., & Holcomb, C. A. (1992). Living arrangements and nutrient intakes of healthy women
age 65 and older: A study in Manhattan, Kansas. Journal of Nutrition for the Elderly, 11,
1-18.
PART III
SPECIAL ISSUES
CHAPTER 17
Health and Well-Being

in Retirement
A Summary of Theories and
Their Implications
WILLIAM S. SHAW, THOMAS L. PATTERSON,

SHIRLEY SEMPLE, AND IGOR GRANT
INTRODUCTION
To consider the topic of retirement as a special clinical issue in this book along-
side the comparatively severe stressors of chronic pain, elder abuse, caregiving,
and bereavement may seem unwarranted to some. Retirement is now a norma-
tive process for most older workers, and available pension and savings plans
have greatly eased the financial burdens of retirement. Yet, for many individu-
als, retirement may represent the single largest lifestyle transition since early
adulthood. Therefore, this period of social development and its mental and
physical health implications have continued to be a subject of theoretical spec-
ulation and empirical study. Retirement may alter family dynamics and social
networks, challenge one's sense of self-worth and accomplishment, and prompt
reprioritization of personal values and interests. The decision to retire may also
be influenced by a complex set of variables, including physical health, occupa-
tional attitudes, personal values, and secular trends. By studying the antecedents
and consequences of retirement, social scientists have sought to identify factors
that contribute to a successful and healthful retirement process.
Retirement, like other experiences of later life, occurs among a tremen-
dously diverse aging population. Health, occupational circumstances, socio-
cultural factors, and other demographic indicators contribute to both retirement
WILLIAM S. SHAW, THOMASL. PATIERSON, SHIRLEY SEMPLE, AND IGOR GRANT • Department of Psychiatry,
School of Medicine, University of California. San Diego. La Jolla. California 92063-0680.
383
384 William S. Shaw et al.
lifestyle and attitudes about the retirement process. For example. variables con-
sistently associated with retirement satisfaction among male retirees (health.
wealth. and work history) appear to be unrelated to satisfaction among female
retirees (George. Fillenbaum. & Palmore. 1984). Another example is the differ-
ence in retirement predictors based on vocational status. Job dissatisfaction is
the strongest predictor of retirement among older blue-collar workers (Goudy.
Powers. & Keith. 1975). whereas self-perceptions of youthfulness and work ef-
fectiveness are the most salient variables for older executives (Eden & Jacobson.
1976). Also. the retirement process itself is changing as demographic shifts and
technological innovations make flexible employment conditions more feasible.
In this chapter. we explore factors that may delineate theoretically relevant sub-
sets of retirees. and we review and contrast the psychological and sociological
theories that have been advanced to explain retirement and its impacts.
A second focus of this chapter is to explore the complex relationships be-
tween physical health and retirement. Despite a widely held notion that retire-
ment is responsible for declining health. we review studies that provide very
little support for this belief. We also discuss the role of health in the decision
to retire and whether this influences retirement outcomes. Although postretire-
ment activities can be compromised by poor health. retirement may provide op-
portunities for improving health behaviors and directing more attention to
treating physical health conditions. In our review oftheoretical models. we ex-
amine in particular the applicability of retirement theories to describe the com-
plex interaction of health and retirement.
DEFINING RETIREMENT AS A PROCESS

In the most basic sense of the word, retirement represents cessation of reg-
ular employment. regardless of circumstances. volition. or consequences. As a
psychological construct. however. retirement represents a much broader con-
cept-it may trigger a series of financial. social. and intrapsychic processes over
an extended transitional period. In a review of gerontological studies of retire-
ment. Quinn and Burkhauser (1990) noted a variety of operational definitions
for categorizing individuals as retired: (1) retirement based on self-appraisal of
perceived retirement status; (2) retirement predicated on receipt of retirement
income or Social Security income; and (3) retirement based on a criterion de-
gree of labor force participation. To remedy these definitional issues. Atchley
(1991) has proposed that retirement occurs at the time at which an individual's
primary financial source shifts from wage earnings to a pension income.
The stereotypical retirement is one of a quick and long-anticipated depar-
ture from full-time employment. and this event is often marked by a retirement
party and the good wishes of fellow workers. This stereotype is accurate for
most workers. The median pattern is to retire from full-time work at age 65 and
permanently leave the work force (Quinn & Burkhauser. 1990). However. in-
creased flexibility in employer retirement policies and diversification of pen-
sion programs have allowed many workers to make gradual retirement
transitions over several years. This provides employers with part-time access to
Health and Well.Being in Retirement 385
an experienced and knowledgeable labor force during peak periods without the
burden of paying full-time employee benefits. For the older worker, part-time
employment helps to ease the transition to retirement and provides a supple-
mental income source. Given these mutual benefits, it is surprising that phased
retirement programs have not been more popular among older workers. Al-
though 60% to 80% of workers of all ages favor a phased retirement (Jondrow,
Breehling, & Marcus, 1987), fewer than one-third eventually chooses part-time
retirement transitions (Gustman & Steinmeier, 1985).
The numerous possible patterns and phases of the retirement transition
have led many researchers to conceptualize retirement as a process rather than
a discrete event. The most influential description ofthis process has been Atch-
ley's (1974) eight phases of retirement: (1) preretirement, in which anticipatory
attitudes are formed; (2) retirement event, marked by a celebratory gesture; (3)
honeymoon phase, marked by vacations and new interests; (4) rest and relax-
ation phase, a period of brief respite from the obligations of work; (5) imme-
diate retirement routine, an immediate readjustment of schedules to maintain
activity; (6) disenchantment, a perceived "letdown" following the honeymoon
phase or as the result of negative circumstances; (7) reorientation, in which ad-
justments are made to accommodate realistic lifestyle goals; and (8) retirement
routine, a stable period in which a satisfying retirement lifestyle is maintained.
Although Atchley (1974) cautions that these stages do not occur in an orderly
and consistent fashion for all individuals, they help to characterize the retire-
ment experiences voiced by many older workers. Empirical studies have shown
support for at least some of these phases of the retirement transition (Antonov-
sky & Sagy, 1990; Ekerdt, Bosse, & Mogey, 1980; Ekerdt, Bosse, & Levkoff, 1985;
Evans, Ekerdt, & Bossee, 1985),
Three principal stages of the retirement process can be consolidated from
the eight stages proposed by Atchley (1974): the retirement planning process,
the retirement decision process, and adaptation to retirement. Retirement plan-
ning typically begins in early adulthood, when a variety of retirement pension
plans are first offered and expectations about life after retirement begin to
evolve. The retirement decision process includes contemplation and actions
immediately preceding the decision to retire. Adaptation to retirement encom-
passes whatever actions are taken to reach a comfortable and satisfying lifestyle
after retirement. Psychological and sociological theories of retirement have ad-
dressed these three stages of the retirement process with varying success. Later
in this chapter, we use these three stages as a context for theory comparison.
Another aspect of retirement that favors a process approach is its voluntary
nature. In the 1950s and 1960s, prior to the 1967 enactment of the Age Dis-
crimination in Employment Act (ADEA), many employers enforced mandatory
retirement, sometimes as early as age 45 (Schulz, 1988). Involuntary or coerced
retirement has been linked to negative attitudes and maladjustment (Schulz,
1988) among retirees (Crowley, 1986; Hardy & Quadagno, 1995) . Since its en-
actment, the ADEA has been amended (most recently in 1986) to abolish
mandatory retirement in America with the exception of a few selected occupa-
tions. Today, retirement is for most a self-guided process that is intimately con-
nected with subjective perceptions of life circumstances.
A BRIEF mSTORY OF RETIREMENT
The ambivalence with which many older workers approach retirement

may be a reflection of the confusing historical origins of retirement in America.
Although touted as a benefit for older workers, retirement was clearly instituted
to benefit younger workers. At the turn of the century, retirement as it exists to-
day was unknown. By mid-century, the industrial revolution had reduced de-
mand for poorly skilled older workers whose primary training and experience
was inconsistent with technological advances. At the same time, life expec-
tancy was increasing rapidly from 46 years in 1900 to 66 years in 1950 (Man-
heimer, 1994), and this resulted in a glut of older workers who were perceived
as limiting the aspirations of younger, more promising candidates. Although re-
tirement today is often considered a positive reward for a lifetime of hard work,
the historical fact remains that retirement was first conceived to limit, not ex-
tend, opportunitites for older workers.
Since the Social Security Act was first passed by Congress in August 1935,
thousands of minor (and some major) adjustments have been made to U.S. fed-
eral government policies concerning retirement programs and pensions. Today,
unraveling the complexities of social security, pension plans, savings plans,
and health care coverage can be a time-consuming and often aggravating
process for many older Americans. Labor force participation rates among older
Americans have steadily declined in response to increasing retirement benefits
(see Figure 17-1). In 1950, 46% of men over the age of 65 were employed, com-
pared with 16% in 1992. Employment rates among women over the age of 65
~ Men • Women
1950 1955 1960 1965 1970 1975 1980 1985 1900 1995
Year
Figure 17·1. Civilian labor force rates among men and women 65 years or older. From
Older Americans Almanac (p. 215), edited by J. Manhelmer, 1994, Washington, DC: Gale
Research. Copyright 1994 by Gale Research Inc.
Health and Well-Being in Retirement 387
have remained surprisingly stable (about 10%) over this period, because the
tendency for women to retire earlier was offset by a growing presence of women
in the workplace in all age groups. Over the past decade, employment rates
among older Americans have remained relatively stable, reflecting a newly es-
tablished balance between the competing influences of labor demands and re-
tirement benefits.
As the baby-boom generation (those born between 1942 and 1963) ap-
proaches retirement age, the demographic factors that originally precipitated the
need for a uniform retirement policy may require adjustment. In 1930, only 5.4%
of the population was over age 65; today, about 12% are over 65; and by the year
2010, approximately 20% of the population will be older than 65. As this demo-
graphic shift continues, it will become increasingly difficult for a shrinking
younger workforce to support the entitlements of a burgeoning group of retirees.
Economic principles of supply and demand within the workforce may lead em-
ployers to encourage delayed retirement among older workers. Recent legislative
changes have already begun to reflect this pattern. For example, the minimum
age to begin collecting Social Security has been raised for future workers (effec-
tive in 2010). Also, income tax laws have been changed to provide for taxation of
the Social Security benefits of upper-income individuals. In the future, these
policies should result in later retirement ages among future cohorts of retirees.
DIVERSITY IN RETIREMENT
One of the difficulties in establishing a single explanatory model of the re-

tirement process is the degree to which circumstances may vary among retirees.
For example, a "stress and coping" model of the retirement process that as-
sumes retirement to be a stressor may be inaccurate for individuals who view
retirement as a long-awaited escape from a stressful, physically demanding, or
dissatisfying occupation. Similarly, theories that view retirement as a normative
disengagement from society are inaccurate for those who choose to augment
physical and social activities after retirement. Very few older workers retire be-
cause they are discouraged with work or are forced to retire by their employer
(see Figure 17-2). Six variables of circumstance have been repeatedly shown to
influence the nature of retirement. These are gender, health, wealth, job satis-
faction, occupational type, and whether retirement is voluntary or involuntary
(see Table 17-1). Examination of these variables is essential before assuming an
accurate theoretical orientation to explain retirement processes.
Given the experiential diversity of retirement, we have chosen a typology of
retirement that specifies four possible retirement possibilities: retirement as a life
stressor; retirement as a relief from employment; retirement as a marker for dis-
ability; and retirement as a developmental task. These can be shown in a decision
logic diagram (Figure 17-3) in which presence or absence of several factors deter-
mines which type of retirement experience is likely to occur. This typology spec-
ifies that if retirement is either involuntary or not preceded by adequate financial
planning, retirement may be best characterized as a stressor. If neither of these
conditions is met, but employment was either dissatisfying or physically de-
manding, retirement may be best characterized as a reward and a relief. If none
388 William S. Shaw et aI.
45
40
35
I/)
CD
~ 30
ia:
25
'0
CD
~ 20
'E
~ 15
rf
10
5
0
Mandatory Health Discouraged Voluntary-early VOluntary-late
Primary Reason Provided for Retirement
Figure 17·2. Primary reasons given for retirement among American men retired in 1981.
From "Longitudinal Effects of Retirement on Men's Well-Being and Health," by J. E.
Crowley, 1986, Journal of Business and Psychology, 1, p. 101.
of these four conditions is met, but retirement was related to disability or declin-
ing health, then retirement merely serves as a behavioral marker for poor health.
If none of these circumstances apply, then retirement is best characterized as a de-
velopmental task requiring interpersonal and intrapsychic adjustments. This re-
duction of retirees into experiential subsets provides more homogeneous groups
in which to understand the retirement process and explain empirical findings.
Gender
Empirical studies of retirement in the past have focused on traditional ca-

reers (auto workers, college professors, and medical and health professionals, for
example) and have focused almost exclusively on men. The growing labor force
participation rates of women warrants increased attention to the role and im-
pacts ofretirement among older female workers. Keith (1985) has identified for-
merly married women as a special group at risk for poor retirement outcomes
because of reduced savings and less employment tenure at retirement. Other re-
search suggests that although retirement outcomes are similar for men and
women, the factors that account for retirement satisfaction are different. George
and colleagues (1984) found that health, income, and work history were predic-
tive of retirement satisfaction for men, but not for women. One explanation for
this difference may be that women today have a narrower range of variability on
measures of health, income, and work history; therefore, correlations with re-
tirement satisfaction tend to be much lower. Another explanation is that married
women's retirement decisions may be highly impacted by their husbands' re-
Table 17-1. Studies Investigating Variables Related to Retirement Satisfaction

Reference Methods Explanatory variables
Glamser (1976) Investigated predictors of retirement Preparedness

attitude among 70 Pennsylvania Financial future rating
factory workers. Life situation rating
Number of close friends
Times unemployed
Dorfman (1989) Investigated predictors ofretirement Health
satisfaction among 451 rural retirees. Financial adequacy
Occupational prestige
Retirement planning
Belgrave & Haug (1995) Investigated predictors ofretirement Health
adaptation among 428 men and women. Family income
Work commitment
Unemployment history
Gregory (1983) Investigated predictors of life Amount of activity
satisfaction among 79 retirees in Enjoyment of activity
Richmond. Virginia. Occupational behavior
Meaningfulness of activity
tirement decisions. Husbands are more likely to have a higher income, longer
tenure in their employment, and more physical health problems. Studies are
needed to further explore the retirement decision process among women.
Another shortcoming of the retirement literature has been its exclusive fo-
cus on the health and well-being of the retiree without examining impacts as to
other family members or family support structures. Although men and women
generally report improved relationships after retirement (Vinick & Ekerdt, 1989),
longitudinal studies of well-being and marital satisfaction fail to show improve-
ments for men or women after retirement. In fact, retirement of married men may
have some negative impacts on the well-being of their wives (Lee & Shehan,
1989). This may be the result of changes in the division of household labor that
lead to interpersonal conflicts after retirement. Although one might predict that
retirement would lead to improved marital relationships because more available
time could be spent together, this hypothesis has not been supported. Retirement
may follow a long phase of the marital relationship in which stability is achieved
within the context of active employment. After retirement, a balance in the rela-
tionship must be reestablished based on a new set of routines and patterns of
communication. Based on the tentative conclusions regarding women and re-
tirement, we have not made any predictions in our decision-logic diagram (Fig-
ure 17-3) about the influence of gender on retirement characterization.
Compulsory Retirement
Compulsory retirement, although highly restricted by recent changes to U.S.

employoment laws, still affects some older workers. College professors, police
officers, prison guards, and fire fighters were the last occupations in which
Retirement as a
Life Stressor
Retirement as a
Relief from Hard
Work
No
Retirement as a
Developmental
Task
Retirement as a
Yes
Marker for
Disability
Figure 17-3. A decision logic diagram for identifying differences in retirement experiences among population subsets.
compulsory retirement was officially abolished in 1993. However, employees of

small businesses and several other exempted groups may still encounter a com-
pulsory retirement age. The percentage of older male workers facing compulsory
retirement has decreased from approximately 50% in the 1960s to less than seven
percent in 1985 (3% for older female workers) (Sherman, 1985). For those few
workers still facing compulsory retirement, a mismatch may exist between the
designated mandatory retirement age and the age at which an older worker feels
"ready" to make the retirement transition. Voluntary retirees report greater well-
being and life satisfaction after retirement than either mandatory retirees or those
continuing to work (Crowley, 1986). Therefore, mandatory retirement may repre-
sent a life stressor that produces negative feelings about the retirement transition.
Today, although few workers face outright compulsory retirement based on
age, many older workers may be coerced or induced to retire, either through fi-
nancial incentives or by subtle attempts to convince older workers that their ca-
pabilities are reduced or skills outdated. Others may be forced to leave their
employment during corporate downsizing and reorganization. Among older
workers who lose their jobs, 28% are reemployed, 10% remain unemployed,
and 62% decide to leave the labor force by retiring early (Manheimer, 1994). In
a study of early retirees from the auto industry, Hardy and Quadagno (1995)
found that both dissatisfaction with retirement and feelings of having "retired
too early" were associated with the experience of undesired transfers and plant
closings. Therefore, retirement may still be perceived by retirees as involuntary
if coercive tactics are used to force an early retirement.
Financial Preparation
For many older workers, economic factors represent the largest single
change associated with the retirement process. During this time, wage earnings
are replaced by social security benefits and other asset and pension sources (see
Figure 17-4). Preretirement income and financial losses associated with retire-
ment have been shown to be related to the decision to retire (George et aJ., 1984)
as well as to satisfaction with retirement (Dorfman, 1989; Palmore, Fillenbaum,
& George, 1984). For most older workers, however, retirement today does not
have the catastrophic financial implications that it held only several decades
ago. On the average, retirees today experience an average reduction in income
of only 25%, from $8,500 to $6,400 (Dorfman, 1989; Palmore et aJ., 1984). Such
income is usually comprised of some combination of social security, pension
plans, retirement savings plans, or entitlements for special or disabled groups.
Although these programs appear to provide most retirees with a satisfactory re-
tirement, poor financial planning may make the retirement process stressful for
some. Of the 30% of retirees who find retirement stressful, poor family finances
is one ofthe primary correlates (Bosse, Aldwin, Levenson, & Workman-Daniels,
1991). For this subset ofretirees, models that characterize retirement as a po-
tential stressor may be most appropriate.
The wide range of financial situations found among retirees has created
dramatic diversity in retirement experiences. This has not always been the case.
100
..... Earnings
90 ...... Asset Income
"
80 ""*- Other Income
-+- Social Security Benefits
CD 70 -0- Other Pensions
E
8 ~
"'"'"
.5 60
S
~ 50
'5 r--...
-""
CD 40 ~
~ ~
c
CD 30 ~
~ ......~
~
8?
....
20
-
~
............... -....
10 C- _ _ _ I . - -
0
Ages 55-61 Ages 62~4 Ages 65-69 Ages 70+
Age Group
Figure 17·4. Sources of income by percentage among older Americans in 1986. From A
Generation of Change: A Profile of America's Older Population (p. 490), by J. S. Siegel,
1993, New York: Russel Sage Foundation. Copyright 1993 by Russell Sage Foundation.
In the 1950s, more than a third of older adults had incomes that fell below the
poverty line. This proportion has decreased dramatically with installment of
social security, increasing availability of retirement pension plans, and in·
creasing popularity ofretirement savings plans. In 1984. only 12% ofretirees
fell below the poverty line (Crystal, 1986). Still. certain groups among older in·
dividuals continue to experience financial difficulties after retirement. partic·
ularly formerly married women (Keith. 1985), members of minorities (Crystal.
1986). and the very old (Crystal, 1986). As a group, however. there is reliable
evidence to suggest that risk of becoming poor is no greater for older adults
than it is for younger individuals (Crystal, 1982. 1986; Danzieger. van der
Gaag. Smolensky. & Taussig. 1984). Among retirees. financial preparedness has
been shown to be a strong predictor of life satisfaction after retirement
(Glamser. 1976).
Recognizing the importance of financial security after retirement. re-
searchers have begun to look at the success of employer-sponsored retirement
preparation programs. Although currently offered by only a few of the largest
employers. these programs have been well received by workers and appear to
improve workers' attitudes about retirement. Abel and Hayslip (1987) found
that workers participating in six weekly 2-hour retirement planning classes
maintained more positive attitudes about retirement and a higher locus of con-
trol for making retirement plans. This study, however. included only one 2-
week follow-up after the 6-week intervention. In a rural sample. Dorfman (1989)
found that retirement preparedness was related to later retirement satisfaction.
Retirement preparation programs. however. remain most popular among work-
ers needing help the least. In a study of older workers volunteering to partici-
pate in retirement preparation programs, Campione (1988) found that partici-
pants tended to be married with children, had no major health problems, and
were of higher occupational status. Future work is needed to develop methods
for recruiting in these programs groups of older workers who are at higher risk
for financial difficulties.
Occupational Characteristics and Employment Satisfaction
A high level of intrinsic job satisfaction may delay the decision to retire. In
cross-sectional studies, older workers show a higher degree of commitment to
their work (Hedges, 1983), and this difference can be explained by the greater
occupational prestige and job satisfaction attained by older workers (Hanlon,
1986). An inverse relationship between job attitudes and retirement attitudes
has been suggested for older workers (Johnson & Strother, 1962), although this
hypothesis has received only marginal support (Eden & Jacobson, 1976; Goudy
et aJ., 1975). The importance of job satisfaction in the decision to retire has been
supported by an apparent preretirement process: as older workers approach re-
tirement, they tend to view their employment as more burdensome and less re-
warding, regardless of age, health, or income (Ekerdt & DeViney, 1993).
For those in extremely stressful or dissatisfying work environments, retire-
ment may represent an escape from the burden of work and an opportunity to
engage in more favorable leisure activities and interests. This subset of retirees
has received little research attention because few workers remain in high-stress
professions as they approach retirement. In addition, dissatisfied employees
have been excluded from research studies because they tend not to participate
in employer-sponsored research protocols. With increased seniority and cre-
dentials, older workers tend to gravitate away from, or be promoted away from,
the most psychologically stressful or least satisfying assignments unless these
come with great financial rewards. Paramedics, air traffic controllers, and urban
police officers are known to transfer to less stressful positions, develop second
careers, or retire early as they build seniority. Still, a sizable percentage of older
workers report that their work makes them nervous or tired (Ekerdt & De Viney,
1993). For these individuals, retirement may be an opportunity to improve
health and well-being.
Another subset of retirees consists of those who find their work satisfying
and rewarding, although the work is physically demanding and involves sub-
stantial risks for injury. For these older workers, muscle strain or chronic con-
ditions may be aggravated by physical aging processes. Retirement offers a relief
from severe physical demands and may provide opportunities for increasing
medical attention to chronic conditions and improving muscle conditioning.
Among blue-collar workers, Jacobson (1972) found that fatigue-producing fac-
tors of employment led to a greater desire to find relief through retirement. Re-
tirees from these occupations experience improved health after retirement
(Ekerdt, Bosse, & LoCastro, 1983), and few continue to engage in activities re-
quiring heavy physical exertion (Kelly, Steinkamp, & Kelly, 1986). Therefore,
retirement may be qualitatively different for workers of physically demanding
occupations than for others. This is one illustration of the impacts of health on
the retirement process. Because health has been frequently cited as both an an-
tecedent and consequence of retirement. we dedicate the next session to ex-
ploring this complex interaction.
HEALTH AND RETIREMENT
A long-standing myth is that retirement signals the onset of a spiraling pat-

tern of health decline among retirees. This is based on the belief that the health
of older individuals depends on "keeping busy" and that reductions in activity
may compromise intellectual and physical functioning. Although retirees as a
group report slightly diminished health after retirement (Fillenbaum. George, &
Palmore, 1985), this effect is probably spurious, reflecting the inclusion of the
few individuals who leave work as a result of failing health. In other words, re-
tirement is merely a marker for the poor health that led some individuals to re-
tire. As an illustration of this common misattribution, Ekerdt (1987) presents
the well-known case of college football coach Paul "Bear" Bryant, who suffered
heart failure and died 37 days after his retirement from coaching. In response to
his death, casual observers were quick to acknowledge that "the Bear should
never have retired," attributing his death to retirement from football. However,
a more detailed reporting of events would later reveal that Coach Bryant retired
as a result of a 3-year illness that eventually took his life. The best-controlled
studies of health and retirement have indicated that retirement does not in-
crease the risk of either death or health deterioration (Ekerdt et aI, 1983; Fillen-
baum et a1., 1985; Kasl, 1980; Minkler, 1981; Palmore et a1., 1984).
The popular belief that retirement leads to poor health continues to prolif-
erate despite contrary research evidence. Ekerdt (1987) provides several expla-
nations for this myth. First, he cites the work of Brim and Ryff (1980), who
reported that "most people, in thinking about life events and their effects on be-
havior, tend to attribute causality to a single, large, vivid, and recent event." Re-
tirement easily meets these criteria. Second. Ekerdt (1987) points out that
popular theories about aging and retirement (reviewed later in this chapter) im-
plicitly suggest that poor health is a logical outcome of retirement, noting both
life event stress models and activity theory models. Third, Ekerdt reasons that
"negative views of retirement are consistent with the cultural ideology that
celebrates work as the source of self-worth. self-esteem. identity, and personal
fulfillment." With these strong influences on the development of scientific hy-
potheses, the question of whether retirement causes poor health is likely to re-
main open to debate.
Although retirement seems to have little direct influence on health, health
may be a major factor in the decision to retire. From 25% to 30% of older work-
ers retire because oftheir failing health (Sherman, 1985). After chronological
age, self-reported health is the strongest single predictor of the decision to retire
(Monahan & Greene, 1987; Taylor & McFarlane-Shore, 1995). However, little is
known about which aspects of health provide the greatest influence on the re-
tirement decision and whether a health rationale for retirement can, in fact, be
justified. We have proposed a biopsychosocial model that incorporates various
aspects of objective and subjective health measures to describe the influence of

health on the older worker's decision to retire (see Figure 17-5). In this model,
health is divided into four constructs: (1) functional health status, an objective
measure of disability, (2) perceived vitality, the subjective component of health
assessment, (3) medical regimen, encompassing patterns of health care use, spe-
cific diagnoses made, and medical treatments prescribed; and (4) health behav-
ior, including diet, exercise, and risk behaviors that influence health status. To
some degree, each of these aspects of health is determined by an individual's
subjective interpretation of symptoms, health attitudes, and health knowledge.
We have included this health mediator in the model as psychological response
to physical signs and symptoms. Psychosocial moderators (e.g., social support,
coping resources, personality factors) may further attenuate the influence of
health on the retirement decision.
Health has repeatedly been shown to correlate with life satisfaction after re-
tirement (Belgrave & Haug, 1995; Dorfman, 1989). Because most retirement
studies have examined health using a global self-assessment, discrete models
like the biopsychosocial model just presented are difficult to support from em-
pirical evidence. A few studies, however, have suggested that some components
of health may influence retirement differentially. For example, Antonovosky
and Sagy (1990) suggested that retirement is coincident with an increased sense
of health maintenance and epidemiological data (Karp, 1988; Siegel, 1993) sup-
port this hypothesis (see Figure 17-6). Therefore, the salience of health to indi-
viduals may be more important in their decision to retire than their health per
se. Another study showed that perceptions of youthfulness were predictive of
Physical
Health
Figure 17-5. Aspects of health related to the retirement decision.

60
-.. Sleeps less than 7 hours
........ Skips breakfast
50 - t - - - - - - - - t - - - - - - - - t - - - - - - - i -.- Snacks every day

~ Sedentary
-0- Heavy drinking
40 + - - - - - - - + - - - - - - - + - - - - - - 1 -0- Smoking
-t:r- Obese
CI)
~
CI)
30
~
If.
20
10
0
Ages 45-54 Ages 55-64 Ages 65-74 Ages 75+
Age Group
Figure 17-6. Percentage of older Americans with selected health practices. From A Gen-
eration of Change: A Profile of America's Older Population (p. 294), by J. S. Siegel, 1993,
New York: Russell Sage Foundation. Copyright 1993 by Russell Sage Foundation.
retirement age among older executives (Eden & Jacobson, 1976). This finding
highlights the importance of perceived vitality (or, conversely, frailty) in the de-
cision to retire.
Older workers who retire for health reasons may be at increased risk for
poor retirement outcomes. These individuals report less satisfaction with re-
tirement (Crowley, 1986; Dorfman, 1989), report retirement to be more stress-
ful (Bosse et al., 1991), and possess greatest risk for poor health after retirement
(Crowley, 1986). Unfortunately, those who retire for health reasons are also less
likely to have engaged in financial planning for retirement (Campione. 1988;
McPherson & Guppy, 1979), and this further complicates affordability ofre-
quired health care services after retirement. Again, it is unclear whether the re-
tirement event itself has any tendency to aggravate chronic health conditions.
As discussed earlier, empirical studies have not supported this hypothesis.
However, older workers with serious health concerns have not been studied as
a separate subset. For this group, the opposite effect may actually exist. Retire-
ment may result in improved health as a result of refocusing one's lifestyle to
accommodate health concerns (e.g., smoking cessation, exercise, dietary im-
provements). In support of this hypothesis, 43% of retirees report improve-
ments in health after retirement (Schnore, 1985).
The myth that retirement leads to health decline has been fueled by the
stereotype that individuals become physically and socially inactive after retire-
ment. This is the primary rationale for the disengagement theory of retirement
that we discuss in the next sections. In fact, inactivity after retirement is rare
(Kelly et a1., 1986; Marino-Schorn, 1986). Instead, activity levels after retire-
ment tend to mirror those experienced throughout the life span. Therefore,
intraindividual differences in activity levels after retirement are minute in
comparison with interindividual differences across the life span.
THEORIES OF RETIREMENT
In 1961, the first theory of social behavior in late adulthood described the
disengagement of older Americans from social participation as a normative de-
velopmental process (Cumming & Henry, 1961). This influential yet controver-
sial "disengagement theory" sparked several competing theories of normal
aging, and these have further guided our exploration of retirement and other ag-
ing phenomena. The following review includes a hybrid list of both retirement-
specific and more general theories of aging. Unlike previous reviews (Burbank,
1986; Jonsson, 1993; L. W. Smith, Patterson, & Grant, 1992) ours focuses on the
application of the various theories to unique phases and circumstances of re-
tirement and the overt or implied incorporation of health considerations into
the theories.
One word of caution is necessary before we proceed with a review of psy-
chological theories of retirement. Although theories of aging are often labeled
developmental theories, this terminology implies both a universality and a bio-
logical determinism that are not empirically supported among older individu-
als. Whereas stages of infant development can be predicted with reasonable
accuracy, developmental stages among older individuals can be extremely di-
vergent and uncertain. Therefore, we prefer to characterize these theoretical
models as probabilistic psychosocial theories of adult behavior that fall within
the social and physiological contexts of aging. Although this argument may
seem purely semantic, it highlights the need to address diversity among older
individuals and avoid ageist beliefs related to reduced capacities.
Disengagement Theory
Disengagement theory proposes that the normative aging process in-

volves a gradual and mutual withdrawal from individuals and society in the
years preceding death. This theory (Cumming & Henry, 1961) is based on
the declining rates of physical and social activity commonly observed
among older individuals. Although this observation is factual, the disen-
gagement theory provides few explanatory mechanisms. Presumably, the
underlying purpose of social disengagement is that there be less disruption
in social networks at the time of death. This theory has received little em-
pirical support and has been criticized as untestable (Hochschild, 1975) and
supporting negative stereotypes (Havinghurst, Neugarten, & Tobin, 1968).
Moreover, this theory is contrary to the evidence that social support is
related to increased life satisfaction at all ages (Neugarten, 1976). Never-
theless, this theory was influential in highlighting the need for further psy-
chological study of lifestyle changes in late life. Disengagement theory
characterized retirement as a step toward reduced status among peers and

termination of collegial relationships.
Earlier in this chapter, we divided the retirement process into three sepa-
rate stages: retirement planning, retirement decision, and retirement adapta-
tion. Table 17-2 summarizes each of the major retirement theories and their
ability to describe each of these three stages. The disengagement theory pro-
vides a framework for the decision to retire, but not for either retirement plan-
ning or retirement adaptation. The disengagement theory would predict that
efforts to retain social standing and increase interaction (to "reengage") after re-
tirement would be maladaptive, opposing empirical findings to the contrary.
Similarly, financial planning for an active retirement would seem to counter the
belief that retirement should be a period of reduced activity and social with-
drawal. Therefore, disengagement theory provides a partial but unsupported
explanation of the reasons people retire. The theory does not, however, attempt
to describe the full range of behaviors and activities associated with the retire-
ment process. Earlier in this chapter. we proposed that the nature of retirement
varies depending on life circumstances (see Figure 17-3). We hypothesized that
retirement may represent a life stressor for some, a relief from hard work for
others, or a marker for poor health for still others. If none of these circumstances
apply, then retirement might be best characterized as a normal developmental
task of adulthood. Because disengagement theory assumes the latter character-
ization of retirement as a developmental task, it ignores the special circum-
stances of retirement that may warrant alternative conceptualizations.
Although health is not specifically included as a factor in the theory of dis-
engagement, it may be the prevalence of poor health among older individuals
that actually spawned this theory of aging. Older Americans report more phys-
ical health symptoms, receive more medical attention, and have more chronic
health conditions than any other age group (Older Americans Almanac; Man-
heimer, 1994). Therefore, one might be tempted to conclude categorically that
older individuals as a group are less equipped to maintain high levels of social
interaction and physical activity. Disengagement theorists may have considered
that social withdrawal would be health adaptive, in that less activity would re-
duce risks for stress and injury. This conclusion is contrary to the belief that so-
cial support may buffer the impacts of poor health. It also fails to address the
majority of older individuals who, by and large, are in good health and have no
physical disabilities.
Activity Theory
In opposition to disengagement theory, Havinghurst and colleagues (1968)

developed a conceptualization of aging that promoted increased physical and
social activity in later life. Referred to as activity theory by Atchley (1976), this
theory suggests that retirement creates a void in peoples' lives that must be re-
placed by other activities. Four primary principles are associated with retire-
ment: (1) retirement from work results in a sense of loss; (2) the focus of this
sense of loss may vary between individuals; (3) satisfactory adjustment to re-
tirement involves substituting something to replace the loss; and (4) the substi-
Table 17·2. A Comparison of Psychological Theories of Retirement
Process best described Characterization of retirement
Implied predictors of
Theory Description Planning Event Adapting Stressor Relief Task Health poor outcome
Disengagement Inevitable and mutual X X Failure to disengage from

social withdrawal is social activities and work
normative and adaptive. relationships.
Activity Postretirement social X X X Failure to replace work
activities are necessary activities with leisure
to replace sense of loss. activities after retirement.
Continuity Lifestyle stability is the X X X X Failure to minimize
key to maintain well- lifestyle impacts of
being. retirement.
Congruence Personally meaningful X X X Mismatch between
activities must be normative retirement
maintained to ensure activities and personal
well-being. values and goals.
Developmental Retirement involves X X X X Failure to advance through
successful completion normative stages of the
and advancement retirement process.
through developmental
stages.
Stress/coping Coping strategies are X X Failure to cope correctly
key to managing the with the stressors of the
stress ofretirement. retirement transition.
Personality Personality traits can X X Possessing strong
predict successful personality traits of
adaptation to retirement. introversion and
neuroticism.
tution typically involves replacing one set of activities for another. The activity
theory is empirically supported by the frequent finding that social activities are
positively correlated with adjustment among postretirement samples (e.g., Gre-
gory, 1983; Havinghurst, Munnicks, Neugarten, & Thomas, 1969; Maddox,
1963). Activity theory also predicts that individuals who expect to experience
the greatest sense of loss after retirement might delay its onset, and this has
been shown among white-collar workers (Mitchell, Levine, & Pozzebon, 1988).
However, the empirical evidence for an actual substitution of activities after re-
tirement is much weaker (Beck & Page, 1988) and increased activities after re-
tirement have been linked to negative as well as positive moods and attitudes
(Reich, Zautra, & Hill, 1987). The activity theory also ignores the possibility that
increased activities are a reflection, not a determinant, of positive adjustment
after retirement.
Activity theory is primarily a model for adaptation to retirement (see Table
17-2). It suggests that poor adjustment to retirement results from a failure to re-
place work-related activities. This belief has achieved widespread popular sup-
port, and community programs for older Americans frequently promote
increased social activity. In recent years, however, social researchers have be-
gun to scrutinize more closely the causal relationships between social support
and improved well-being and health. Metanalyses have indicated that social ac-
tivity is only modestly correlated with subjective well-being (Okun, Stock, Har-
ing & Witter, 1984) and is unrelated to recovery from illness (Reifman, 1995;
C. E. Smith, Fernengel, Holcroft, Gerald, & Marien, 1994). Also, physical illness
may have a tendency to mobilize greater support, further complicating the
causal relationship between social support and health (Grant, Patterson, &
Yager, 1988). Therefore, the primary thesis of the activity theory, that a consis-
tent level of social activity is necessary for maintaining well-being after retire-
ment, is becoming more suspect. Studies that are better equipped to dissect the
bidirectional influences between social activity and well-being after retirement
are needed.
An activity theory. of retirement assumes that retirement is either a health
marker (in the case of voluntary retirement) or a potential stressor (if retirement
is involuntary). One shortfall ofthe activity theory is that, with the exception of
poor health, it provides no explanation of the reasons for retirement. If maxi-
mizing activity levels is the key to well-being, why should a worker choose re-
tirement over continued service? Perhaps the decision to retire is driven
principally by the social influence of secular trends. Another explanation might
be that retirement marks the time at which leisure activities become more de-
sirable than work activities. As originally proposed, however, the activity the-
ory does not specify the types of activities that are more helpful to alleviate the
sense Of loss experienced after retirement.
Because activity theory is primarily a theory about social behavior, physi-
cal health behavior was not included in its inception. Perhaps this is because
physical and social activities are less distinguishable among older individuals.
Nevertheless, physical health may be the spurious variable driving the correla-
tions between activity and well-being after retirement that form the basis for
this theory. Depressed mood and reduced social activity in postretirement years
may be independent responses to deteriorating health. Both have been linked to
poor health in older individuals with chronic health conditions (Grant et al.,
1988). Therefore, activity levels may reflect physical limitations, rather than vo-
litional responses to a sense of loss after retirement. This is particularly likely
given the apparent importance of health in the decision to retire (Fillenbaum
et al., 1985; McPherson & Guppy, 1979; Taylor & McFarlane-Shore, 1995).
Continuity Theory
Rosow (1963) observed that well-adjusted adults in their peak years (early
to middle 50s) appeared to experience few life changes. Individuals from this
age group were typically past stages of rapid career advancement, relocations,
responsibilities of child rearing, and other lifestyle transitions. From this he
concluded that life satisfaction is negatively correlated with change. Empirical
support comes from retrospective studies that report more successful retire-
ment adjustment among those experiencing the fewest lifestyle changes in re-
tirement (Long, 1987). These studies have focused primarily on white-collar
workers, and measurements of lifestyle change have not been objectively vali-
dated. Like the disengagement and activity theories, the continuity theory of re-
tirement lacks specificity. By labeling change as an agent of maladjustment, the
benefits of positive lifestyle changes are ignored.
In a study of leisure activities among older workers, only those activities
characterized as "core" activities seemed to maintain continuity over time
(Kelly et al., 1986). These included family, social, and home-based activities. In
contrast, recreational activities, exercise, and travel showed consistent reduc-
tions with age. This provides some support for the continuity theory over the
activity theory, in that meaningful activities appeared constant over time, and
no increase in leisure activities was observed after retirement. The activity the-
ory, on the other hand, would predict that leisure activities should increase af-
ter retirement in order to fill the void left by reduced work-related activities.
The continuity theory also predicts that workers should be weary of the
lifestyle and social transitions of retirement. This appears to be true for many
older workers. Retirees are often hesitant to retire, and their estimated retire-
ment age increases as they approach their original estimated departure date (Ek-
erdt et al., 1980). However, the continuity theory also predicts that retirees
should welcome opportunities to engage in part-time work and this is not the
case. Only 20% of retirees are interested in part-time employment after retire-
ment (Toughill, Mason, Beck, & Christopher, 1993).
Like activity theory, continuity theory is better at predicting adaptation to
retirement than explaining why older workers retire. However, the continuity
theory also provides an explanation for why workers engage in retirement plan-
ning: to attenuate the lifestyle impacts of retirement. Early investments in re-
tirement savings plans, for example, help to offset the financial losses of
retirement and thereby increase lifestyle continuity. Successful retirement plan-
ning may prevent lifestyle changes such as relocating, giving up club member-
ships, or reducing social functions after retirement. Continuity theory, then,
may help explain the desire to minimize the financial impacts of retirement.
Like activity theory, continuity theory assumes retirement to be either a stressor
(in the case of involuntary retirement) or a marker for poor health (when retire-
ment is voluntary). It is also similar to the activity theory in that it provides no
explanation for why individuals should choose to retire.
Congruence Theories
We have chosen to use a single heading, congruence theory, to describe a

number of theories of retirement that emphasize the subjective interpretation of
meaningful activity. Like the activity and continuity theories, congruence the-
ories focus on activity as the key to successful retirement adaptation. Congru-
ence theories, however, go one step further by attaching personal salience
ratings to individual activities. These theories have included accommodation
theory (Shanas, 1972), adjustment theory (Atchley, 1976), and the model ofhu-
man occupation (Jonsson, 1993). Each of these theories seeks to group activities
based on their subjective meaningfulness to individuals. For example, adjust-
ment theory (Atchley, 1976) states that internal compromises are made in re-
tirement that produce changes in one's hierarchy of personal goals. These value
adjustments result in the changes in desired activities that constitute retire-
ment. Similarly, the accommodation theory (Shanas, 1972) claims that changes
in behavior after retirement occur because of changes in perceived needs or
self-concept. The model of human occupation (Jonsson, 1993) predicts that
postretirement activities involve a balance between work, rest, and leisure and
that chosen activities are based on ratings of personal meaningfulness.
The goal of congruence theories was to incorporate specificity with regard
to activities and to explain their differential relationships with life satisfaction
after retirement. Each theory has received some empirical support. However,
differences in terminology and psychological constructs have prevented at-
tempts to consolidate these ideas into a single cohesive model of retirement.
Like the activity and continuity theories, congruence theories describe primar-
ily adaptation to retirement. Because congruence theories depend on subjective
interpretations of activities, retirement might be characterized as either a stres-
sor or a relief, depending on the perceived meaningfulness of work activities
prior to retirement. Unlike the activity or continuity theories, congruence theo-
ries of retirement provide an explanation of the reasons for retirement: people
are responding to a set of revamped values, personal goals, or life meaning.
If retirement is part of an age-related shift in personal goals and interests as
the congruence theories suggest, then changing attitudes about health may also
be a part of this transitional period. At retirement age, individuals are more
likely to acknowledge their own mortality and perceive their physical condi-
tions as potentially life threatening. If we return to our biopsychosocial model
of health and retirement (Figure 17-5), the congruence theory might predict that
the psychological response to physical health is amplified in later life and that
this results in heightened perceptions of disability, frailty, medical needs, and
health risks. These changes in health perceptions may partially influence the
decision to retire; the conclusion is supported by the relationships between
health and retirement (Fillenbaum et a1., 1985; McPherson & Guppy, 1979; Tay-
lor & McFarlane-Shore, 1995). However, the importance of other factors in the
decision to retire may sometimes overshadow the role of health perceptions

(Belgrave & Haug, 1995).
Developmental Theory
The developmental theory of retirement is sometimes referred to as the

salutogenic model or the sense of coherence model. This theory (Antonovsky,
1979; Antonovsky & Sagy, 1990) describes the retirement transition as a series
of developmental tasks that lead to positive well-being and increased life satis-
faction. Although very similar to congruence theories of retirement, the devel-
opmental theory is the first to represent retirement as both voluntary and
process-based. In this theory, based loosely on the last two stages of Erikson's
well-known life-cycle model, social reintegration and disintegration occurs as a
process involving four factors: active involvement, reevaluation of life satisfac-
tion, reevaluation of world outlook, and the sense of health maintenance. Ac-
tive involvement describes challenges throughout the life span, but especially
after retirement, to reorganize activities in response to changes in personal goals
or societal expectations. Reevaluation of life satisfaction is the challenge for
older adults to provide meaning and direction in their lives based on reflecting
on and consolidating past accomplishments. Reevaluation of world outlook is
the challenge to integrate knowledge and experiences into coherent and global
attitudes about social order, science, religion, and the role of mankind. The
fourth factor, sense of health maintenance, occurs as a result of increases in
morbidity and mortality rates after age 55. Because the developmental theory
does not characterize retirement as a single event, it is flexible enough to pro-
vide explanations for retirement preparation, the retirement event, and adapta-
tion to retirement (see Table 17-2). For example, reevaluation of world outlook
may begin to occur long before the actual date of retirement. Life experience
and the evolution of both professional and social roles may foster changes in at-
titudes throughout the life span, and retirement may be just one by-product of
this attitudinal process. After retirement, world outlook may continue to
change in response to the shift from a work setting to other roles. The devel-
opmental theory suggests that the retirement event is merely a milestone for
life-span changes in each of the four factors. The developmental theory is em-
pirically supported by evidence for a preretirement process (Ekerdt & DeViney,
1993; Evans et a1., 1985), changes in preferred retirement ages over time (Ekerdt
et a1., 1980; Ekerdt, Vinick & Bosse, 1989), and phased changes in satisfaction
after retirement (Ekerdt et a1., 1985).
The developmental theory of retirement is the only psychological model
that incorporates health as a component to the retirement transition. Its fourth
factor, sense of health maintenance, recognizes the changing attitudes about
health that seem to co-occur with retirement (Fries & Crapo, 1981). If we con-
sider our biopsychosocial model for the impacts of health on the decision to
retire (Figure 17-5), the sense of health maintenance factor from the develop-
mental theory is consistent with our recognition that both health behaviors and
perceived vitality may impact the decision to retire. As age-equivalent peers be-
gin to experience more disabling or life-threatening illnesses, an individual, by
social comparison, is more likely to feel vulnerable. Thus, more time might be
spent in health contemplation, health-promoting activities, or grieving losses in
physical vitality. More detailed studies of the changing health philosophies of
older adults are needed.
Stress and Coping Theory
In the stress model, an individual's reaction to retirement depends on the

degree to which retirement is perceived as stressful or threatening (Lazarus &
Folkman, 1984). A number of variables, including the effectiveness of one's
coping responses and the abundance and quality of social support available,
may mediate the relationship between retirement and adjustment. George
(1980) differentiates between coping responses, which consist of behavioral
and intrapsychic reactions, and other moderating and mediating variables, in-
cluding demographics, situational factors, or personality characteristics. Stress
and coping models have been more descriptive than explanatory, including
multiple variables and many potential relationships between variables (L. W.
Smith et aI., 1992).
Stress and coping models of retirement have viewed retirement as a life
event occurring within the context of personal meaning, threat appraisal, and
contextual variables (Grant et aI., 1988; L. W. Smith et al., 1992). Coping re-
sponses-the behavioral and cognitive reactions intended to reduce stress-
may be more or less appropriate for specific stressors. This belief has spawned
attempts to grade the appropriateness of particular coping strategies for specific
types of stressors (L. W. Smith et aI., 1992). Stress and coping models have pre-
dominated in the study of aging and health. Symptoms of chronic illness, death
of a spouse, and other life events have been characterized as stressors that re-
quire the use of coping skills to attenuate negative emotional impacts of these
events. Retirement, for some, may have similar qualities. As we have indicated
earlier (see Figure 17-3), retirement may be a stressor only under special cir-
cumstances; for example, when retirement is involuntary or coerced, or when
individuals are financially ill prepared for their retirement years. Therefore,
stress and coping models of retirement may be applicable only for those who
experience unfortunate circumstances linked to their retirement transition.
In other applications, the primary outcome of stress and coping models has
been diminished mental health or physical health or both. Although several un-
derlying mechanisms have been proposed to link stressors to poor health out-
comes, the primary paths have been via depressed mood or other symptoms of
depression. Depression is strongly correlated with physical health symptoms,
presumably because depression leads to reduced immunity or reductions in
healthy behaviors. Others have speculated that depression may be simply an
early reflection, rather than an agent, of physical health symptoms. In studies of
retirement, the primary outcome has been life satisfaction, not depressive
symptoms. However, these two variables appear to be strongly correlated as
well. Therefore, for those individuals who are at risk for depression, dissatis-
faction with life after retirement may contribute to depressive symptoms which,
in turn, may lead to increased symptoms of physical illness. The stress and cop-
ing model of retirement may provide a useful theoretical framework in which to

study the effects of retirement among a depression-prone subgroup, for exam-
ple, a group of older workers with histories of affective disorders. For many
other retirees, the stress and coping model appears to be inconsistent with em-
pirical data that suggests only minor fluctuations in life satisfaction at the time
of retirement.
Personality Theories
One recent addition to retirement theories has been the incorporation of
personality traits as moderators of retirement outcomes. We include this brief
addition as a separate theoretical category because conventional psychological
variables such as personality traits have been noticeably absent from theories of
retirement. As early as 1979, researchers noted that personality variables such
as Type A behavior, orientation toward planning, and inner-directedness may
be important to retirement adaptation (Atchley, 1976). Yet, few studies have in-
vestigated this possibility. Recently, Reis and Pushkar-Gold (1993) have sug-
gested that successful adaptation to retirement may be related to the personality
traits of hardiness, neuroticism, attachment, introversion, and personal flexi-
bility. Although empirical studies have yet to test these hypotheses, the signifi-
cant influence of personality on many other aspects of behavior would suggest
a probable role in retirement. It is doubtful, however, that personality variables
alone would provide the best model for understanding retirement preparation,
the retirement decision, and adaptation to retirement for most older workers.
As we have suggested with previous theoretical frameworks, personality
traits might be used to identify subgroups of older workers at high risk for poor
retirement outcomes. Broader psychological theories of personality and psy-
chopathology provide some support for this hypothesis. Attachment theory, for
example, might predict that because retirement involves the dissolution of in-
terpersonal relationships, it may result in feelings of loss or hostility in those
who are insecurely or anxiously attached to their coworkers. For older workers
who have some tendencies to be socially introverted, eccentric, or dysthymic, re-
tirement may represent a difficult social transition. No empirical studies have
examined the impacts of retirement to these at-risk populations of older workers.
SUMMARY
Implications of Theories
What do the aforementioned theories suggest about the nature of retire-
ment? Although most of these theories describe retirement as a discrete event,
we suggest that the developmental theory, which describes retirement as part of
a long-term developmental process, may be more accurate. Three theories
(stress and coping theory, activity theory, and continuity theory) portray retire-
ment as an externally controlled event that requires adjustment and adaptation
by the individual. In contrast, the remaining four theories provide for the role
of the individual in planning for and scheduling their own retirement. The lat-
ter theories seem more relevant today, given the voluntary nature of retirement
for most older workers. The congruence and developmental theories are the
most dynamic of the theories because they accent the underlying importance of
changing attitudes and interests during the retirement process. A personality
theory of retirement is helpful to highlight the contribution of psychological
characteristics, not just demographic characteristics, to the retirement process.
Empirical tests of the various theories of retirement have been few, and these
studies have focused on limited professional and demographic subgroups. In
general, the disengagement theory has received the least support, and the activity
theory has received the most. Variables frequently cited to impact retirement sat-
isfaction are health, wealth, retirement preparation, activity levels, and vocational
type (see Table 17-1 for a partial listing of empirical studies). Studies of large, in-
clusive samples have demonstrated only slight variations in life satisfaction,
health, and emotional distress during the retirement transition. Few studies, how-
ever, have identified population subgroups that may be more susceptible to mal-
adjustment during the retirement transition. Special at-risk groups might include
individuals facing mandatory retirement, those with greatly diminished income
after retirement, those with high-risk personality features or psychiatric histories,
those who retire due to ill health or caregiving, or those who are experiencing
concurrent life stressors (e.g., relocation, bereavement).
Why is a theoretical framework necessary to study the phenomenon of re-
tirement? The goal of retirement research is to understand what factors might
lead to improved quality of life after the traditional "working years." Theories
help to provide hypothesized causal links that can be empirically supported or
rejected. They also help to narrow the focus of studies to only the most salient
features responsible for causal influences. Theory development has recast re-
tirement as a process rather than an event. It has also led us to consider vari-
ables that might increase the risks for poor retirement outcomes. As we have
suggested here, it is not likely that a single theory will be sufficient to describe
the retirement process for all older workers. Instead, a number of theories may
be applicable depending on the circumstances of retirement, individual per-
sonality traits and values, and life history. More theory-based empirical studies
of retirement are necessary in order to determine the most important factors
contributing to satisfying retirement processes among special groups.
The Changing Face of Retirement
Why should retirement remain an important field of study in clinical

geropsychology? Past evidence suggests only slight fluctuations in most out-
come variables throughout the retirement transition, at least when heteroge-
neous and inclusive samples of retirees are studied. Nevertheless, future
demographic and workplace changes may raise new questions about retire-
ment. The "aging of America" as baby boomers reach retirement age with in-
creased life expectancies will continue to generate interest in issues of aging
such as retirement. Also, it appears that the normative age for retirement may
gradually increase over the next fifty years. As this occurs, the psychological
and health impacts of "nonretirement" may become a concern for those who
would rather be retired.
Continuing changes in employment policies may also change the nature of
retirement. During the past decade, the percentage of employees entitled to re-
tirement benefits has begun to drop off, and the number of subcontracted em-
ployees has continued to grow. These employees must save (e.g., 402b) for their
own retirements. Social Security benefits have been reduced and the defini-
tions for receiving benefits have become more stringent. These forces suggest
that new patterns of retirement and its meaning should emerge in the next 20 to
30 years. Finally, interest in retirement is fueled by a recognition that older in-
dividuals have been ignored in many areas of psychological study, and this has
resulted in a shift from studying human development as a childhood process
to studying it as a life-span process. There are probably fewer studies of retire-
ment today than there are of the effects of school transfers among children, yet
retirement affects a much larger population. For these reasons, increased inter-
est in the psychological developmental processes of aging and probable changes
in retirement itself are likely to fuel continued interest in retirement, its an-
tecedents, and its consequences.
REFERENCES
Abel, B. J., & Hayslip, B. (1987). Locus of control and retirement preparation. Journals of Gerontol-
ogy. 42, 165-167.
Antonovsky, A. (1979). Health, stress and coping. San Francisco: Jossey-Bass.
Antonovsky, A., & Sagy, S. (1990). Confronting developmental tasks in the retirement transition.
Gerontologist, 30. 362-368.
Atchley. R. C. (1974). The meaning ofretirement. Journal of Communications. 24. 97-101.
Atchley. R. C. (1976). The sociology of retirement: Schenkman.
Atchley, R. C. (1991). Social forces and aging (6th ed.). Belmont. CA: Wadsworth.
Beck. S. H .. & Page. J. W. (1988). Involvement in activities and the psychological well-being of re-
tired men. Activities, Adaptation &- Aging, 11,31-47.
Belgrave, L. L., & Haug, M. R. (1995). Retirement transition and adaptation: Are health and finances
losing their effects? Journal of Clinical Geropsychology, 1,43-66.
Bosse, R.. Aldwin, C. M., Levenson, M. R., & Workman-Daniels, K. (1991). How stressful is retire-
ment? Findings from the Normative Aging Study. Journals of Gerontology, 46, P9-P14.
Brim, O. G., & Ryff, C. D. (1980). On the properties of life events. In P. B. Baltes & O. G. Brim (Eds.),
Life-span development and behavior (Vol. 3, pp. 368-388). New York: Academic.
Burbank, P. M. (1986). Psychosocial theories of aging: A critical evaluation. Advances in Nursing
Science, 9, 73-86.
Campione, W. A. (1988). Predicting participation in retirement preparation programs. Journals of
Gerontology, 43, S91-S95.
Crowley, J. E. (1986). Longitudinal effects ofretirement on men's well-being and health. Journal of
Business and Psychology, 1,95-113.
Crystal, S. (1982). America's old age crisis: Public policy and two worlds of aging. New York: Basic
Books.
Crystal, S. (1986). Measuring income and inequality among the elderly. Gerontologist, 26, 56-59.
Cumming. E., & Henry, W. H. (1961). Growing old: The process of disengagement. New York: Basic
Books.
Danzieger, S., van der Gaag, J., Smolensky, E., & Taussig, M. (1984). Implications for the relative eco-
nomic status of the elderly for transfer policy. In H. Aaron & G. Burtless (Eds.), Retirement and
economics behavior (pp. 175-196). Washington, DC: Brookings Institution.
Dorfman, 1. T. (1989). Retirement preparation and retirement satisfaction in the rural elderly. Jour-
nal of Applied Gerontology, 8, 432-450.
Eden, D., & Jacobson, D. (1976). Propensity to retire among older executives. Journal of Vocational
Behavior, 8, 145-154.
Ekerdt, D. J. (1987). Why the notion persists that retirement harms health. Gerontologist, 27, 454-457.
Ekerdt, D. J., & DeViney, S. (1993). Evidence for a preretirement process among older male work-
ers. Journals of Gerontology, 48, S35-S43.
Ekerdt, D. J., Bosse, R., & Mogey, J. M. (1980). Concurrent change in planned and preferred age ofre-
tirement. Journals of Gerontology. 35, 232-240.
Ekerdt, D. J., Bosse, R., & LoCastro, J. S. (1983). Claims that retirement improves health. Journals of
Gerontology. 38, 231-236.
Ekerdt, D. J., Bosse, R., & Levkoff, S. (1985). An empirical test for phases ofretirement: Findings
from the Normative Aging Study. Journals of Gerontology, 40, 95-101.
Ekerdt, D. J., Vinick, B. H., & Bosse, R. (1989). Orderly endings: Do men know when they will retire?
Journals of Gerontology. 44, S28-S35.
Evans, 1., Ekerdt, D. Jo, & Bosse, R. (1985). Proximity to retirement and anticipatory involvement:
Findings from the Normative Aging Study. Journals of Gerontology, 40. 368-374.
Fillenbaum, G. G., George, 1. K., & Palmore, E. B. (1985). Determinants and consequences of retire-
ment among men of different races and economic levels. Journals of Gerontology, 40, 85-94.
Fries, J. F., & Crapo. L. M. (1981). Vitality and aging. New York: Freeman.
George, L. K. (1980). Role transition in later life. Monterey: Brooks/Cole.
George, L. K., Fillenbaum. G. G., & Palmore, E. (1984). Sex differences in the antecedents and con-
sequences of retirement. Journals of Gerontology, 39, 364-371.
Glamser. F. D. (1976). Determinants of a positive attitude toward retirement. Journals of Gerontol-
ogy, 31, 104-107.
Goudy, w. J., Powers, E. A., & Keith, P. (1975). Work and retirement: A test of attitudinal relation-
ships. Journals of Gerontology. 30, 193-198.
Grant, 1., Patterson, T. 1., & Yager. J. (1988). Social supports in relation to physical health and symp-
toms of depression in the elderly. American Journal of Psychiatry. 145,1254-1258.
Gregory, M. D. (1983). Occupational behavior and life satisfaction among retirees. American Jour-
nal of Occupational Therapy, 37, 548-553.
Gustman, A. L., & Steinmeier, T. 1. (1985). The effects of partial retirement on wage profiles of older
workers. Industrial Relations, 24, 257-265.
Hanlon. M. D. (1986). Age and commitment to work. Research on Aging, 8, 289-316.
Hardy, M. A, & Quandagno, J. (1995). Satisfaction with early retirement: Making choices in the auto
industry. Journals of Gerontology, 50, S217-S228.
Havinghurst, R. J., Neugarten, B. 1., & Tobin, S. S. (1968). Disengagement and patterns of aging. In
B. 1. Neugarten (Ed.), Middle age and aging: A reader in social psychology (pp. 223-237).
Chicago: University of Chicago Press.
Havinghurst, R. J., Munnicks, J. M., Neugarten. B. 1., & Thomas, H. (1969). Adjustment to retire-
ment: A cross-sectional study. New York: Humanities.
Hedges, J. N. (1983). Job commitment in America: Is it waxing or waning? Monthly Labor Review,
106.17-24.
Hochschild, A. R. (1975). Disengagement theory: A critique and proposal. American Sociological
Review, 4, 553-569.
Jacobson, D. (1972). Fatigue-producing factors in industrial work and preretirement attitudes. Oc-
cupational Psychology, 46, 193-200.
Johnson, J.. & Strother, G. B. (1962). Job expectations and retirement planning. Journals of Geron-
tology, 17,418-423.
Jondrow, J., Breehling, F., & Marcus. A. (1987). Older workers in the market for part-time employ-
ment. In S. H. Sandell (Ed.). The problem isn't age: Work and older Americans (pp. 81-98).
New York: Praeger.
Jonsson, H. (1993). The retirement process in an occupational perspective: A review of literature
and theories. Physical & Occupational Therapy in Geriatrics, 11, 15-34.
Karp, D. A. (1988). A decade of reminders: Changing age consciousness between fifty and sixty
years old. Gerontologist, 28, 727-738.
Kasl, S. V. (1980). The impact ofretirement. In C. 1. Cooper & R. Payne (Eds.), Current concerns in
occupational stress (pp. 171-193). New York: Praeger.
Keith. P. M. (1985). Work. retirement. and well-being among unmarried men and women. Geron-
tologist, 25. 410-416.
Kelly. J. R. Steinkamp. M. Woo & Kelly, J. R (1986). Later life leisure: How they play in Peoria.
Gerontologist, 26. 531-537.
Lazarus. R S., & Folkman, S. (1984). Stress, appraisal, and coping. New York: Springer.
Lee, G. R, & Shehan. C. L. (1989). Retirement and marital satisfaction. Journals of Gerontology, 44,
S226-S230.
Long. J. (1987). Continuity as a basis for change: leisure and male retirement. Leisure Studies, 6, 55-70.
Maddox. G. 1. (1963). Activity and morale: A longitudinal study of selected elderly subjects. Social
Forces,42,195-204.
Manheimer. R J. (Ed.). (1994). Older Americans almanac. Detroit: Gale Research.
Marino-Schorn. J. A. (1986). Morale. work and leisure in retirement. Physical & Occupational Ther-
apy in Geriatrics, 4, 49-59.
McPherson, B., & Guppy, N. (1979). Pre-retirement life-style and the degree of planning of retire-
ment. Journals of Gerontology. 34, 254-263.
Minkler, M. (1981). Research on the effects of retirement: An uncertain legacy. Journal of Health
and Social Behavior, 22,117-130.
Mitchell. O. S .• Levine. P. B.. & Pozzebon. S. (1988). Retirement differences by industry and occu-
pation. Gerontologist, 28, 545-551.
Monahan. D. J., & Greene, V. L. (1987). Predictors of early retirement among university faculty.
Neugarten. B. L. (1976). Adaptation and the life cycle. Geriatric Psychiatry, 6, 16-20.
Okun. M. A.. Stock, W. A .• Haring, M. J.• & Witter. R A. (1984). The social activity/subjective well-
being relation: A quantitative synthesis. Research on Aging, 6,45-65.
Palmore. E. B., Fillenbaum. G. G., & George. 1. K. (1984). Consequences ofretirement. Journals of
Gerontology, 39 (1),109-116.
Quinn. J. F.• & Burkhauser. R V. (1990). Work and retirement. In R H. Binstock & 1. K. George (Eds.).
Handbook of aging and the social sciences (pp. 263-281). San Diego, CA: Academic.
Reich. J. W.• Zautra. A. J., & Hill. J. (1987). Activity. event transactions. and quality of life in older
adults. Psychology and Aging, 2, 116-124.
Reifman. A. (1995). Social relationships, recovery from illness and survival: A literature review. An-
nals of Behavioral Medicine, 17, 124-131.
Reis. M .. & Pushkar-Gold. D.P. (1993). Retirement. personality. and life satisfaction: A review and
two models. Journal of Applied Gerontology. 12,124-131.
Rosow. H. (1963). Adjustment of the normal aged. In R H. Williams. C. Tibbits, & W. Donahue
(Eds.). Processes of aging (Vol. 2. pp. 195-223). New York: Atherton.
Schnore, M. (1985). Retirement: Bane or blessing? Toronto, Ontario, Canada: Wiffird Laurier Uni-
versity Press.
Schulz. J. H. (1988). The economics of aging (4th ed.). Dover. MA: Auburn House.
Shanas. E. (1972). Adjustment to retirement: substitution or accommodation? In F. M. Carp (Ed.).
Retirement (pp. 219-243). New York: Behavioral Publications.
Sherman, S. R. (1985). Reported reasons retired workers left their last job: Findings from the New
Beneficiary Survey. Social Security Bulletin, 48, 22-30.
Siegel. J. S. (1993). A generation of change: A profile of America's older population. New York: Rus-
sell Sage Foundation.
Smith. C. E.. Fernengel, K.. Holcroft. C.• Gerald. K.. & Marien. 1. (1994). Meta-analysis of the asso-
ciations between social support and health outcomes. Annals of Behavioral Medicine, 16,
352-362.
Smith. L. W.. Patterson, T. L.. & Grant. I. (1992). Work. retirement. and activity: Coping challenges
for the elderly. In M. Herson (Ed.). Handbook of social development: A life-span perspective
(pp. 475-502). New York: Plenum.
Taylor. M. A .• & McFarlane-Shore, L. (1995). Predictors of planned retirement age: An application
of Beehr's model. Psychology and Aging, 10, 76-83.
Toughill. E.• Mason. D. J.. Beck. T. 1.. & Christopher. M. A. (1993). Health. income. and postretire-
ment employment of older adults. Public Health Nursing, 10, 100-107.
Vinick. B. R .• & Ekerdt. D. J. (1989). Retirement: What happens to husband-wife relationships? Jour-
nal of Geriatric Psychiatry, 24, 23-40.
CHAPTER 18
Pain Management
DEBRA S. MORLEY AND DAVID I. MOSTOFSKY
INTRODUCTION
Despite the increased interest in understanding age-related changes, and in de-

veloping service delivery systems for the expanding aging and elderly popula-
tions, there is a paucity of effort directed toward the effective utilization of
behavioral theory and technologies in the analysis and remediation of pain
problems in older adults. The accelerating nationwide increase in the elderly
population, combined with the many behavior problems and deficits associ-
ated with their increased longevity, has contributed to the emergence of be-
havioral gerontology as an identified specialty, although there remains a
relative lack of interest and research activity in the larger community of be-
havioral researchers concerning the problems of older individuals (Wisocki &
Mosher, 1982). The need for an understanding of these problems is critical if
we are to establish the basis for training and education of professional and
other health specialists versed in the psychosocial aspects of comprehensive
geriatric and gerontological management.
The elderly population is increasing. Older people are living longer, even
when struck by catastrophic events (e.g., after experiencing strokes) and their
vulnerability to pain leads to deterioration of the quality of life. Retrospective
reports from surviving significant others of 200 deceased older community res-
idents indicate that pain increased over the final year; 1 month before death,
66% experienced pain frequently or all the time. This was much higher than a
matched comparison group of living persons (24%). Not surprisingly, these re-
ports made clear that pain contributed significantly to a decrease in happiness
and to depression (Moss, Lawton, & Glicksman, 1991).
Changes in health and mortality rates at later ages are important consider-
ations for pain management. For example the 1960-1990 U.S. annual stroke
DEBRA S. MORLEY • Department of Psychology. Boston University. Boston. Massachusetts 02215.

DAVID I. MOSTOFSKY • Laboratory for Experimental Behavioral Medicine. Department of Psychol-
ogy. Boston University. Boston. Massachusetts 02115.
411
412 Debra S. Morley and David I. Mostofsky
mortality rate dropped 65.2%; for ages 85 and over, stroke mortality rates
dropped 55.6%. The decline in total mortality for the entire U.S. population
from 1960 to 1990 was 31.7%. For those 85 and over, the total mortality rate
was 22.8% (Manton, 1997). Mortality rates for some deaths increased; for ex-
ample, U.S. cancer mortality rates increased, including those for prostate can-
cer and female breast cancer. Relevant for our consideration is that the terminal
stages of these cancer conditions are very painful and hard to manage.
With the dramatic changes taking place in medical health care organiza-
tions, and with an emphasis on the need to reduce the costs of hospital and
drug charges (not to mention the likelihood of the attending iatrogenic compli-
cations that too frequently result from polypharmacy, especially in the elderly),
use of behavioral protocols as primary or adjunctive interventions for pain con-
trol deserves serious consideration. Apart from economic pressures, programs
and protocols must be developed that foster optimal conditions for extending
independent living and an improved quality of living for the competent elderly.
Pain left unattended is a major impediment to these goals. The prevalent med-
ical or illness model of treatment is affected, in part, by cultural and profes-
sional ageism, and governed by the assumption of the inevitability of the aging
process. This model tends to assign "sick roles" to older persons and postulates
the irreversibility of problem behaviors. The most common treatment method
for these behaviors and problems (especially when accompanied by dementia)
relies on medication to the exclusion of any behavioral alternatives.
Depression and Pain
There are clear and powerful implications for pain management in both in-
stitutionalized or independent resident older persons; there is a compelling
need to address issues of depression as an adjunctive if not primary factor in the
etiology, modulation, and maintenance of pain associated with global discom-
fort. Psychological states such as depression have the potential to confound the
treatment and assessment of pain. Depression can be masked by pain, and vice
versa. Further, the intensity of existing depression or of a chronic pain condi-
tion may be aggravated by the presence of the other. The relationship between
depression and pain may be intensified because older adults are at risk for an
increased prevalence of both pain-producing ailments and depression (Kwen-
tus, Harkins, Lignon, & Silverman, 1985). The association between depression
and pain appears to vary as a function of age (Turk, Okifuji, & Scharff, 1995).
Turk and colleagues studied 100 chronic pain patients divided into a group of
younger patients (~ 69 years of age) and another group of older patients (~ 70
years of age). In the younger patient group, there was a low and nonsignificant
association between pain severity and depression, whereas there was a signifi-
cant association between pain and depression in the older patient group. An
opposing view is represented by Gagliese and Melzack (1997), who reviewed a
number of studies that have shown no age differences in the severity of depres-
sive symptoms experienced by chronic pain patients, including Gagliese and
Melzack (1995), Herr, Mobily, and Smith (1993), McCracken, Mosley, Plaud,
Gross, and Penzien (1993). Middaugh, Levin, Kee, Barchiesi, and Roberts (1988),
Pain Management 413
Sorkin, Rudy, Hanlon, Turk, and Stieg (1990). In a study examining depression
among chronic back pain sufferers, Herr and colleages (1993) failed to find any
significant differences in the relationship of age and depressed mood between
an elderly and a nonelderly group. The only significant finding about the rela-
tionship of age and depressed mood was that the elderly experienced fewer to-
tal hours per day in pain.
The neurotransmitter serotonin is common to both depression and pain,
and this may account for the effectiveness of antidepressants in combating pain.
Because depression and pain is more prevalent in the elderly, but most research
on pain and psychological function has been done with younger populations,
research applicability to aged populations is tenuous.
Part of the confounding nature of depression in older adults is that with fail-
ing health people experience more pain. In a study of 224 elderly subjects, sub-
jective measures of physical health, such as pain and attitudes about one's own
health, had a stronger association with depression than did more objective mea-
sures such as chronic diseases and functional limitations (Beekman. Kriegsman,
Deeg, & van Tilburg, 1995). Crook, Rideout, and Browne (1984) reported that age-
specific morbidity rates for persistent pain increased with age in a large epi-
demiological study of 500 randomly selected patients from a family practice.
Depression appears to be closely linked with physical health. According to Bruce,
Seeman, Merrill, and Blazer (1994), findings from the MacArthur Study of Suc-
cessful Aging imply that depression and ill health influence each other. Poor
physical health is a risk factor for depression in the elderly and depression may
increase the risk of poor physical health. In a survey of 204 sufferers of chronic
pain, depression was noted as one of the worst problems as a result of the chronic
pain (Hitchcock, Ferrell, & McCaffery, 1994). Research findings ofthis kind re-
quire us to consider "wellness" programs for the elderly in which exercise and
exposure to physical training are incorporated as part of the regular prophylactic
and interventional programming for pain management. Such physical activities
will likely go far in offsetting other age-related medical hazards whether or not
they are causally linked to eventual pain and discomfort. The removal of con-
founding health problems implies the concurrent removal of potential added
medication programs and sources of depression over failing health status.
Strong associations between pain and depression among elderly persons
exist among those living in nursing homes as well as those living indepen-
dently. For example. Cohen-Mansfield and Marx (1993) found, in a study of 408
nursing home residents with differing levels of cognitive impairment, that those
who were depressed were more likely to be experiencing pain. Similarly,
Parmelee, Katz, and Lawton (1991) obtained a significant relationship between
pain and depression in a study of 598 nursing home and congregate apartment
residents. Those with greater pain reported more depressive symptoms. G. M.
Williamson and Schulz (1992) noted that pain and depression were correlated
in a sample of community-residing elderly outpatients. Williams and Schulz
(1988) found a direct relationship between depression and pain severity. That
depressed elderly are more sensitive to pain than nondepressed elderly may be
seen in Parmelee and colleagues' study, which found that those with possible
major depression reported a greater amount of intense pain and had more pain
complaints than did those with minor depression. Functional complaints were
not more common among depressed than nondepressed. Rather, the depressed
had a tendency to overstate pain complaints when there was a recognized
health problem. Pain was studied in a group of 51 depressed elderly inpatients
and 71 control subjects (Magni, Schifano, & DeLeo. 1985). They found that
those patients suffering from dysthymia and atypical depression had the high-
est pain scores. Those patients suffering from major depression and adjustment
disorder with depressive mood had lower scores. Pain is an often neglected area
of research in the nursing home as may be seen from a study by Ferrell, Ferrell,
and Osterweil (1990) who evaluated 97 patients from a 411-bed multilevel
nursing home and found that 71 % of the residents had at least one pain com-
plaint, 34% with constant pain and 66% with intermittent pain.
Pain may function to conceal functional deficits (McIntosh, 1990) or as a
means for getting attention, and as a result depression may be understated. For
example, McCullough (1991) states that depression may be masked as pseudo-
dementia, somatization, or anxiety, or it may be an underlying factor in pain or
alcohol abuse. According to J. Williamson (1978), some elderly might mask de-
pression with complaints of physical symptoms, such as pain, in an effort to
avoid seeking help for or admitting to emotional issues. In contrast, others found
no support for pain as a symptom of masked depression (Parmelee et al., 1991;
Williams & Schulz, 1988). One must be cautious about surveys of depression and
even diagnoses of depression. In a large study of 1,048 elderly subjects, Stewart
and colleagues (1991) found that between 1 % and 5% have major depression.
They concluded that depression is underdiagnosed in older patients and that the
best indicators of depression in older patients are multiple somatic complaints.
Anxiety and Pain

The relationship between anxiety and pain is not as well researched or un-
derstood as the association between depression and pain. The level of anxiety re-
ported by older chronic pain patients appears to be lower than that reported for
younger patients (Corran, Helme. & Gibson, 1993; McCracken et al., 1993). One
study with a small number of subjects found no age difference (Middaugh et aJ.,
1988) but another (Garron & Leavitt, 1979) found a small positive relationship of
anxiety to pain although a correlation of depression with pain was not found.
Casten, Parmelee, Kleban, Lawton, and Katz (1995) investigated the relationship
between depression, anxiety, and pain in institutionalized elderly. Utilizing Di-
agnostic and Statistical Manual of Mental Disorders, 3rd edition, revised (DSM-
III-R; American Psychiatric Association, 1987) criteria, the Profile of Mood States
(PaM), and the number of pain complaints and intensity, they concluded that
anxiety, compared with depression, is more significantly related to pain.
Treatment Outcomes
Geriatric patients benefit from pain center treatment as much as younger pa-
tients (Cutler, Fishbain, Rosomoff, & Rosomoff, 1994). In one study, chronic pain
patients were placed in three groups: geriatric, middle-aged, and younger. After
Pain Management 415
pain center treatment, the geriatric group demonstrated a significant and mean-
ingful improvement. Geriatric patients showed as great an improvement as the
middle-aged and younger groups in the majority of measures utilized. Middaugh
and colleagues (1988) found that geriatric patients profit just as much as, if not
more than, than younger patients from chronic pain rehabilitation programs.
With rare exceptions, the concern with pain as it relates to the specific con-
siderations of aging has been poorly documented. Despite the increased life in-
cidence of pain associated with the elderly suffering from chronic and acute
illnesses, there is often a neglected appreciation that proper pain management
can ameliorate depression and vice versa. Admittedly, much has been written
on the general subject of pain. Yet, a cautious observation seems justified: that
inferences about pain from younger populations may not hold true for older
persons, given the possible confounding presence of dementia, cognitive
changes and decline, and an altered physiology (e.g., slower metabolism).
Psychophysics of Pain
Concerns with assessment issues, which have long plagued the scientific
progress in the area of pain, present added problems when dealing with older
adults. For example, it appears that, perhaps because of a long history with prior
pain, older persons perceive more pain (chronic and acute) than younger persons
(Closs, 1994), and may actually have different thresholds compared to younger
groups (Yehuda & Carasso, 1997), although there are conflicting findings regard-
ing pain threshold in the elderly (Collins & Stone, 1966; Harkins, Price, &
Martelli, 1986; Sherman & Robillard, 1960). Chapman (1978), Sherman and Ro-
billard (1964), and Schludermann and Zubek (1962) all report an increase in the
pain threshold in older persons, whereas Procacci and colleagues (1974) report a
decrease in sensitivity to pain in elderly. Others have found no change in pain
threshold as a function of age (Birren, Shapiro, & Miller, 1959; Hardy, Wolff, &
Goodell., 1943; Harkins & Chapman. 1976, 1977a; Mumford, 1965; Notermans,
1966; Schumacher, Goodell, Hardy, & Wolff, 1940). There also appear to be dif-
ferences between young and old with regard to tolerance or threshold (or both) of
pain level. A consensus in the research literature shows a decrease in pain toler-
ance in older persons; it appears that older persons are less able to cope with the
pain (Collins & Stone, 1966; Harkins & Chapman, 1977b; Woodrow, Friedman,
Siegalaub, & Collen, 1972). According to Zoob (1978), pain is a function of age. As
a person ages, there appears to a decrease in sensitivity to pain. Fordyce (1976),
on the other hand, states that older persons complain more of pain. Clark and
Mehl (1973) try to bridge these contradictory results by proposing that the elderly
just report more pain, and that this does not necessarily imply a greater sensitiv-
ityto pain. This would deny that altered physiology, psychological attitudes, and
a reluctance to confirm the presence of pain may all contribute to raise the pain
threshold. Indeed, for many elderly, pain is believed to be a normal part of aging
(Ferrell et al., 1990) and, therefore, they may not seek help and not infrequently
may then go on to develop clinical depression as a result.
Chronic pain, which may be defined as the persistence of pain in the ab-
sence of any biological predisposing cause or significance, is considered to be
more widespread in older persons than younger persons. Pain in the presence
of pathology might be reported less often; however, in contrast to the situation
with younger patients, chronic pain may have a greater impact on psychologi-
cal, social, and physical function of older adults (Gibson, Katz, Corran, Farrell,
& Helme, 1994).
ASSESSMENT ISSUES
Proper assessment of pain is needed for effective management. Too often,

however, chronic pain goes undetected even in nursing homes where it is a fa-
miliar problem. This is a problem with both noncommunicative and commu-
nicative patients. In a study by Sengstaken and King (1993), physicians failed to
detect pain in 34% ofresidents and, overall, pain was assessed less frequently
among noncommunicative residents. The authors concluded that direct ques-
tioning at frequent intervals should be undertaken and that new assessment
tools need to be created for the noncommunicative resident.
There are essentially two types of psychometric tools for use in the assess-
ment of pain: (1) unidimensional instruments that are suitable for determining
pain intensity, and (2) multidimensional instruments for measuring qualitative
features of the pain experience (Melzack & Katz, 1992). These tools were de-
signed for application with younger persons and there are potential problems if
they are to be uncritically used with elderly populations. Caution must be used
when interpreting results from traditional psychometric tools. If such tests must
be used, it is advisable to ensure that the elderly patient clearly understands the
directions and has the cognitive capacity to undertake such testing. Currently,
there are no pain assessment measures specifically developed for use with older
adults. An example of a frequently used unidimensional tool is the Visual Ana-
log Scale (VAS; Huskisson, 1974). Patients are asked to place a mark on a line
that represents the continuum from "no pain" to "worst pain possible." Kremer,
Atkinson, and Ignelzi (1981) suggest that older individuals who have a deficit
in abstract reasoning may have a problem with using such a scale. The McGill
Pain Questionnaire (MPQ; Melzack, 1975) is an example of a multidimensional
pain inventory; it consists of 20 sets of adjectives describing sensory, affective,
evaluative, and miscellaneous aspects of pain. Herr and Mobily (1991) con-
clude that the MPQ may be too complicated and may take too much time to
complete for use by older adults. A less complex assessment tool that might be
preferable to use with older persons is the short form of the MPQ (SF-MPQ;
Melzack, 1987). The SF-MPQ consists of 15 descriptors from the MPQ; pain in-
tensity is measured on a VAS.
TREATMENT
Pharmacological Control
A thorough discussion of pharmacological management of pain and its rel-

evance to older persons is beyond the scope of this chapter. Although pharma-
cology is the initial treatment of choice for elderly patients experiencing
Pain Management 417
chronic or acute pain, care must be taken when dispensing medication for older
adults because they have an increased sensitivity to and reduced metabolism
far many drugs (Kaiko, Wallenstein, Rogers, Grabinski, & Houde, 1982). The in-
terested reader will find numerous reports and monographs, including a recent
critical review by Cherny and Popp (1997). We examine the essential elements
that govern the judicious use of medicinal treatments.
For what may be considered "routine aches and pains" accompanying old
age, the conventional medical wisdom is to prescribe nonprescription medica-
tion beginning with as Iowa dose as may be clinically effective. The rationale
behind such a plan is to guard against contraindications with other more nec-
essary medications and to prevent interference with proper nutritional intake,
sleep, or optimal neuromuscular and cognitive functioning. When pain be-
comes severe enough to interfere with normal activities, and when the quality
of life begins to seriously deteriorate, stronger and more effective medic antsbe-
come justified. This is especially true for the management of pain associated
with cancer. The WHO "Three Step Analgesic Ladder" (nonopioid, opioid, and
adjuvant analgesics) provides basic guidance for undertaking drug therapy for
cancer pain (Agency for Health Care Policy and Research, 1994). Analgesic
treatment can be classified into three broad categories: nonopioid analgesics,
opioid analgesics, and adjuvant analgesics.
Nonopioid Analgesics
For mild to moderate pain, nonopioid analgesics are preferred. Even for
more severe pain they can be used in combination with opioid drugs. Included
in this category are acetaminophen, aspirin, and other nonsteroidal anti-
inflammatory drugs (NSAIDS). Acetaminophen is included in this category,
even though it does not have much anti-inflammatory effect (Ferrell, 1991). A
"ceiling effect" wherein increasing dosages beyond a certain level no longer in-
creases the analgesic effects is associated with these drugs (Kanter, 1984). It
must be recognized that there are risks with using NSAIDS drugs in older per-
sons; adverse reactions include gastrointestinal bleeding (Alexander, Veitch, &
Wood, 1985), peptic ulcer disease (Butt. Barthel, & Moore, 1988), and renal in-
sufficiency (Maniglia, Schwartz, & Moriber-Katz, 1988).
Opioid Analgesics
Opioid therapy is preferred for moderate to severe pain such as cancer pain
(Portenoy, Foley, & Inturrisi, 1990). This category includes propoxyphene,
codeine, and morphine, among others. There are no "ceiling effects" with these
drugs. Side effects with older persons can include opioid-induced constipation
(Sykes, 1991), nausea (Campara et aJ., 1991), cognitive disturbance, respiratory
depression, and habituation (Ferrell, 1991).
Adjuvant Analgesics
Adjuvant analgesics do not have their own analgesic properties, but are
helpful in treating some types of chronic pain (Ferrell, 1991). Included in
this group are antidepressants, anticonvulsants, sedatives, and corticosteroids.
Corticosteroids are widely used as an all-purpose adjuvant analgesic (Ettinger &

Portenoy, 1988). Amitriptyline is the most effective tricyclic adjuvant analgesic
and is especially useful when the neuropathy is of a burning or dysaesthetic
quality (Onghena & Van Houdenhove, 1992). Tricyclics have anticholinergic
side effects such as constipation, urinary retention. hypotension, and confusion
(Schuster & Goetz, 1994). Benzodiazepines might be effective against insomnia
and anxiety associated with pain, but might lead to daytime sedation, falls, and
confusion. Adjuvant analgesics have the benefit of simultaneously treating con-
current symptoms of depression and anxiety.
Behavioral Coping: Behavioral Intervention Techniques

for Pain Management
Behavior modification, cognitive treatment, relaxation training, exercise,

biofeedback, imagery, diaphragmatic breathing, and hypnosis are all techniques
that can help manage pain in older persons. Some are utilized and more adapt-
able than others for the older patient. Certain techniques, such as behavior
modification and cognitive therapy, might be more intense and take more time
and practice, and although biofeedback might not be cost-effective, exercise, re-
laxation training, and imagery are all easy to complete for most elderly patients.
Hypnosis might be a more difficult procedure and some patients might be re-
sistant to it.
Techniques such as body positioning can offer pain relief. Nelson, Taylor,
Adams, and Parker (1990) found that older adults with hip fractures found
some pain relief when their legs were supported by pillows while in bed. Also,
older persons who received back massages experienced a reduction in level of
anxiety (Fraser & Kerr, 1993).
Unfortunately, many older adults, especially those living in long-term res-
idential care facilities, have become resigned to pain, and they have become
ambivalent regarding any changes in their pain status (Yates, Dewar. & Fenti-
man, 1995). Many studies have investigated behavioral treatments for pain. but
only a few studies have incorporated geriatric patients in their research.
It is important to keep in mind that older patients might appreciate the ben-
efits of certain pain management techniques differently from younger patients.
Differences were found between older patients (65 to 82) and younger patients
(25 to 63) with rheumatoid arthritis or osteoarthritis with regard to their ability
to employ and to benefit from combined treatment approaches (Davis, Cortex,
& Rubin, 1990). Davis and colleagues found that medication, rest, heat, distrac-
tion, and talking to others were most often used by the older patients with med-
ication, rest, and heat being most helpful. Younger patients, on the other hand,
participated in more combined methods and found relaxation techniques as be-
ing a significantly more beneficial procedure. Portenoy and Farkash (1988) sug-
gested that older people might not be good candidates for psychological
treatments aimed at alleviation of pain. They further state that older adults are
rarely given opportunities to utilize psychological treatments that are already
available. There are some older people, those with hearing or memory prob-
lems, for whom psychological treatment might not be effective; however. the
Pain Management 419
majority of elderly. given the chance. can be expected to benefit greatly from
psychological interventions.
Behavior Modification
There are not many studies on the efficacy of behavior modification specif-
ically designed for elderly pain patients. Nevertheless. Fordyce (1986) states
that chronic pain patients of all age groups can benefit from behavior modifica-
tion techniques. Behavior change problems basically consist of (1) behavior that
is not occurring often enough and needs to be increased or strengthened. (2) be-
havior that is occurring too much and needs to be diminished or eliminated. (3)
behavior is missing that is needed and should be learned or acquired. or a com-
bination of (1). (2). and (3) (Fordyce. 1976). The interested reader is advised to
consult Fordyce and colleagues (1973) for a more detailed and complete de-
scription of various behavior modification techniques.
Contingency management is a behavior modification procedure based on
principles of operant conditioning. Operant conditioning and behavior analysis
may help explain to varying degrees the pain exhibited by chronic pain pa-
tients. If in fact such pains result from a history ofreinforced "learning trials."
learning theory principles may be applied to diminish that pain. The goal of
contingency management for chronic pain is to help the patient change pain be-
haviors. The probability or frequency of limping. asking for medications. gri-
macing. moaning. complaining of pain. or not exercising often can be changed
by following contingency management programs. Pain behaviors can become
reinforced by contingencies in the environment and then become learned or ha-
bitual, regardless of whether the contingencies are obvious to the patient. We
may consider an example of a pain patient who has incorporated in the reper-
toire of pain behaviors a profound limp. Regardless of how the behavior began
it is now a learned behavior; one that has been reinforced by environmental
contingencies. One form of treatment might be repeated walking practice. This
is the behavior that needs to be increased. with limping as the targeted pain be-
havior to be decreased or diminished. The reinforcers used to increase the
walking activity could be rest and therapist approval (or any number of other
desirable consequences). That is. walking a certain distance leads to rest and
therapist approval. However. it is important that the patient be reinforced only
when he or she walks without limping. If the patient walks while limping.
limping as a pain behavior will become strengthened. The patient might be in-
structed to initially walk two steps and then be allowed to limp. After two steps
without limping. a brief rest period is allowed and therapist approval is given
(see illustration in Fordyce. 1976).
Cognitive-Behavioral Techniques
Cognitive treatment for pain. which retains many features of the classical
contingency management programs to which have been added "behaviors" or
"stimuli" that might be in the realm of thought or imagery. also addresses de-
pression and personality problems. Many chronic pain patients exhibit mal-
adaptive thinking. which in turn. leads to increased subjective levels of pain
(Thrk & Meichenbaum, 1994). Cognitive treatment would then be directed to-
ward influencing patient's maladaptive and distorted patterns of thinking and
toward helping them change to more productive and positive ways of coping
with pain. Cognitive treatment encourages patients to take more control of their
situations and to better understand the connections between emotions, think-
ing, and the experiences of pain. Most studies utilizing cognitive-behavioral
techniques have utilized younger patients, although there is no reason to be-
lieve that older patients cannot benefit just as well.
Stress-Inoculation Therapy
Stress inoculation combines cognitive methods with positive self-state-
ments and behavior management skills and usually consists of three phases: (1)
education, (2) coping, and (3) application (Masters, Burish, Hollon, & Rimm,
1987). The education phase includes a "conceptualization of pain that stresses
sensory, affective and cognitive components of the pain experience" (Thrk,
cited in Meichenbaum, 1977). In the coping phase, the patient may be taught to
properly engage relaxation strategies to reduce tension and stress associated
with the pain (although goal-directed imagery and distraction can also be uti-
lized). In the final phase of the "application," patients can be subjected to the
actual pain and be able to put to use the techniques they have mastered for pain
control. In a study with 69 chronic pain outpatients who underwent a 10-week
cognitive-behavioral stress inoculation group therapy program (mean age 53,
with 22 patients over age 60), treatment had limited and little effect on per-
ceived intensity of pain, however, there was an increase in the capability to
cope with pain and a decrease in medication usage (Puder, 1988).
Relaxation Techniques
Relaxation techniques include progressive muscle relaxation, imagery, and
controlled breathing that can be used separately or in combination. Relaxation
training is a cost-effective way for any age group to manage pain, and relaxation
training has been helpful in reducing medication usage (Arena, Hightower, &
Chong, 1988). It is believed that relaxation training is helpful as a pain manage-
ment tool because of its effect on sympathetic nervous system activity (Houston,
1993). Diaphragmatic or controlled breathing or both can help with pain manage-
ment. As with relaxation training, this is a variation that often employs progres-
sive and imaginal relaxation training, which have proven effective in decreasing
anxiety levels in elderly patients (Scogin, Rickard, Keith, Wilson, & McElreath,
1992). This important study found that older persons who imagined muscle ten-
sion release benefited as much as those who employed actual tension release,
even at i-month follow up. This is a significant benefit for those older persons
who have physical problems that might otherwise preclude them from actually
tensing and releasing muscles. Similarly, modified progressive muscle relaxation
has been found to be helpful with elderly tension headache suffers (Arena, et a1.,
1988). Their study evaluated an 8-week modified progressive muscle relaxation
protocol administered to 10 elderly subjects with tension headaches. At 3-month
follow-up, significant reductions in headache activity (50% or greater) were
Pain Management 421
found in 7 patients. Significant reductions were also found in the number of

headache-free days, peak headache activity, and medication usage.
According to Wisocki and Powers (1997), three clinical case studies have
been reported in which older persons benefited from relaxation techniques. A
male 89-year-old nursing home resident used taped relaxation instruction with
background music that proved helpful in reducing headache pain (Linoff &
West, 1982). An elderly female patient utilized relaxation techniques with suc-
cess to help cope with the emotional side effects from chemotherapy long after
chemotherapy treatment had terminated (Hamburger, 1982). After 7 weeks of
treatment with relaxation and imagery, an elderly male with severe rheumatoid
arthritis and moderate depression reported a 50% decrease in pain and a sig-
nificant improvement in mood (Czirr & Gallagher, 1983).
Exercise
Regrettably, although even those at advanced age can benefit from exercise
(Fiatarone et aI., 1990), compliance rates for home exercise and self-pain man-
agement is low (Bradley, 1989). The success of such programs depends on a
number of factors, not least of which is the consideration that exercise programs
for elderly pain patients may need to begin at a less strenuous level than might
be advisable for younger pain patients. Exercise programs for older adults can
range from non strenuous yoga techniques (Bender, 1992) to more strenuous wa-
ter exercise programs (Meyer & Hawley, 1994). Results of such programs have
generally been encouraging. Representative findings include studies in which
participation in a water exercise decreased the pain and increased the strength
of older persons with rheumatic disease when compared with a control group
of patients (Meyer & Hawley, 1994). In another investigation, yoga exercises
were significantly beneficial for relief of pain in the hands of patients with os-
teoarthritis compared with a control group (Garfinkel, Schumacher, Husain,
Levy, & Reshetar, 1994).
Elderly myocardial infarction patients who engaged in regular aerobic ex-
ercise reported less chest pain 6 to 12 months after the myocardial infarction
(Fridlund, Hogstedt, Lidell, & Larson, 1991) and improved rehabilitation efforts
after the myocardial infarction (Dixhoorn, Duivenvoorden, Pool, & Verhage,
1990). In a study with mixed ages of MI patients, those in the exercise group
had less anginal pain in 6- to 12-month follow-up compared to the control
group (Stern, Gorman, & Kaslow, 1983). Perhaps such outcomes can modify the
reluctance of physicians to prescribe exercise for treatment; currently less than
half of all older post-MI and bypass patients (62 to 92) are so advised (Ades,
Waldmann, McCann, & Weaver, 1992). Examples of specific exercise programs
that take into consideration a variety of conditions can be found elsewhere
(Bender, 1992; Biegel, 1984; Flatten, Wilhite & Reyes-Watson, 1988; Herning,
1993; Kerlan, 1991; Lehr & Swanson, 1990; Saxon & Etten, 1984)
Biofeedback
A derivative of learning-based therapy, biofeedback, which is based on the
knowledge ofresults of biological states and events, has been successful in pain
control. Strong criticism of biofeedback is that it is not cost-effective and that
less costly techniques, such as relaxation and imagery, might provide the same
results (Achterberg, Kenner, & Lewis, 1988). Biofeedback is not extensively em-
ployed with older patients, but some studies provide empirical support for its
continued use. For example, a 69-year-old male who had a 37-year history of
chronic cluster headaches realized an almost 100% reduction in PRN medicine
as well as a decrease in reports of pain following treatment with thermal
biofeedback and a spouse contingency program (King & Arena, 1984). These de-
creases were maintained at a 15-month follow-up. Electromyographic biofeed-
back training with elderly tension headache patients has also been shown to be
effective (Arena, Hannah, Bruno. & Meador, 1991). Eight patients above the age
of 62 participated in a 12-session frontal EMG training. At 3-month follow-up,
four patients had significantly decreased their headache activity by at least
50%, and three patients decreased headache activity by 35% to 45%. There was
also a reduction in headache-free days, peak headache activity. and use ofmed-
ication. Biofeedback successfully reduced pain and stiffness in an 80-year-old
osteoarthritic pain patient; the patient was taught to maintain proper blood flow
by not contracting the muscles around the joints, thus alleviating pain (Bocz-
koski,1984).
Age alone certainly should not constitute any constraint or limitation for
employing such procedures. Middaugh, Woods, Kee, Harden, and Peters (1991)
did not find any age differences in the use of biofeedback and relaxation tech-
niques for patients with chronic musculoskeletal pain. Older patients (55 to 78
years old) were able to learn physiological self-regulation techniques, such as
relaxation training, diaphragmatic breathing, and EMG biofeedback, just as well
as younger patients (29 to 48 years old). The age groups had similar deficiencies
and complaints on initial evaluation and both groups achieved the same level
of improvement with training.
Hypnosis
Modern-day applications of hypnosis in pain control has been utilized in
various medical conditions, such as helping burn patients better tolerate de-
bridement (Patterson, Everett, Burns. & Marvin, 1992) and dressing changes
(Van der Does, Van Dyck, & Spijker, 1988), as anaesthesia for pain control for
colonoscopy patients (Cadranel et aI., 1994), and as an alternative to the use of
intravenous sedation in interventional radiology (Lang & Hamilton, 1994).
Compared to controls, hypnotized patients were better able to tolerate angio-
plasty longer and required less additional narcotic pain medication (Weinstein
& Au, 1991). Hypnotic suggestions were used to aid in the motor movement re-
covery of left arm function in a 66-year-old woman (Holroyd & Hill, 1989). Pa-
tients with refractory fibromyalgia found hypnosis to be more effective in
relieving symptoms than physical therapy (Haanen et a1., 1991). Forty patients
were randomly to either hypnotherapy treatment or physical therapy treatment
for 12 weeks with follow-up at 24 weeks. Significant improvement was noted in
the hypnotherapy group with regard to pain experience, fatigue on awakening,
sleep pattern. and global assessment at 12 and 24 weeks.
Several studies have investigated the biochemical correlates of hypoanal-
gesia (Domangue, Margolis. Lieberman, & Kaji, 1985), although the connection
Pain Management 423
between the analgesic effects of hypnosis and its neurochemical correlates is

still poorly understood (DeBenedittis, Panerai, & Villamira, 1989). In a sample
of 19 arthritic pain patients, plasma levels of beta-endorphin, epinephrine, nor-
epinephrine, dopamine, and serotonin were measured pre- and posthypnotic
suggestion and decreases in pain, anxiety, and depression were noted following
hypnotherapy, accompanied by an increase in beta-endorphin-like immunore-
active material (Domangue et al., 1985)
Hypnosis is a tool that has great potential to alleviate pain, especially in the
older population and especially for those who might not be able to tolerate cer-
tain medications. As with any application, when electing hypnosis for pain
management, attention should be given to the degree of hypnotizability, atti-
tudes, expectations, and beliefs of the patient in modulating the pain experi-
ence (Chaves, 1994).
Transcutaneous Electrical Nerve Stimulation (TENS)
The analgesic properties of Transcutaneous Electrical Nerve Stimulation

(TENS) are attributed to its ability to stimulate neural pathways and to impede
transmission of pain information to higher levels of the nervous system
(Portenoy & Farkash, 1988). TENS can be used as part of a larger pain manage-
ment program and has been particularly successful with cases of chronic neu-
ropathy, postfractures, cancer pain, low-back pain, postherpetic neuralgia,
myofascial pain, and phantom-limb pain (Thorsteinsson, 1987). Johnson, Ash-
ton, and Thompson (1992) found TENS to be an effective analgesic treatment
for a wide range of pain problems in 58.6% of 1,582 patients who attended their
pain clinic over a period of 10 years, with a number of patients using this treat-
ment for many years. They concluded that TENS can be utilized as a simple,
safe and reusable first line treatment for many pain conditions. Deyo, Walsh,
Martin, Schoenfield, and Ramamurthy (1990) evaluated TENS, stretching exer-
cises, and a combination of the two for treatment of lower-back pain and con-
cluded that TENS was no more effective than placebo. They further stated that
TENS treatment did not add any advantage to the treatment of exercise alone. A
study with 107 chronic pain patients (Johnson, Ashton, & Thompson, 1991)
demonstrated that 47% of patients using TENS decreased their pain by more
than half. There has been some controversy regarding the use of TENS with pa-
tients who have pacemakers, although Rasmussen, Hayes, Vlietstra, and
Thorsteinsson (1988) consider it safe for most patients who have permanent
cardiac pacemakers.
SUMMARY
This chapter provided an overview of the essential considerations in the

generation, maintenance, and potential psychological processes for control of
pain in the aging population. No single volume (and certainly no single chap-
ter) is able to embrace all of the details that are necessary for effective design
or utilization of a treatment intervention. Some sense of the complexity of the
interrelatedness of the issues is represented in Figure 18-1. A useful summary

ofthe principles for programs with elders has been provided by Melding (1997)
in the following guidelines.
• Accept pain as "real"
• Stabilize health status
• Use appropriate analgesia as necessary
• Treat depression vigorously
• Enlist social and family support especially if behavior modification is
needed
• Use cognitive behavioral approaches
• Build self-efficacy by experiential methods rather than didactic teaching
• Pace programs at client's speed
• Keep sessions short. one major concept at a time
• Give plentiful information. keep it simple and use large print fonts
• Set goals with individual, monitor progress with charts. instruments. re-
view frequently
• Reduce catastrophic thinking
There is a real need for health professionals of all disciplines to recognize
(1) the need to address pain management in the older patient and (2) the vast ar-
mamentarium of behaviorally-based interventions that is already available.
•I
I
Impf'D' Increase! Disability
I Aging I • Hypothalamic-
&til(
I Disease and
illness
I I
Pituitary-
"-
r Limbic axis
J
..... JI'
'W-
Psychological
events
Neuroendocrine I Pain
I
t
responses
t
predisrses to
t
Symptoms of
Enhanced
perCePjiOn of
anxiety, fear,
dysphoria,
demotivation
Figure 18.1. A summary ofthe essential and converging elements that affect pain in the
aging. From "Psychiatric Aspects of Chronic Pain" (p. 197). by P. S. Melding. in Chronic
Pain in Old Age: An Integrated Psychosocial Perspective. edited by R. Roy, 1995,
Toronto: University of Toronto Press. Adapted by permission.
Pain Management 425
REFERENCES
Achterberg, J., Kenner, C., & Lewis, G. (1988). Severe burn injury: A comparison of relaxation, im-
agery, and biofeedback for pain management. Journal of Mental Imagery, 12, 71-87.
Ades, P. A., Waldmann, M. L., McCann, W. J., & Weaver, S. O. (1992). Predictors of cardiac rehabil-
itation participation in older coronary patients. Archives of Internal Medicine, 152,
1033-1035.
Agency for Health Care Policy and Research. (1994). Cancer pain management panel. Management
of cancer pain. Clinical Practice Guideline Number 9. Washington, DC: U.S. Department of
Health and Human Services.
Alexander, A. M., Veitch, G. B., & Wood, J. B. (1985). Anti-rheumatic and analgesic drug usage and
acute gastro-intestinal bleeding in elderly patients. Journal of Clinical and Hospital Pharmacy,
10,89-93.
(3rd ed. rev.). Washington, DC: Author.
Arena, J. G., Hightower, N. E., & Chong, G. C. (1988). Relaxation therapy for tension headache in the
elderly: A prospective study. Psychology and Aging, 3, 96-98.
Arena, J. G., Hannah, S. L., Bruno, G. M., & Meador, K. J. (1991). Electromyographic biofeedback
training for tension headache in the elderly: A prospective study. Biofeedback and Self Regu-
lation, 16,379-390.
Beekman, A. T., Kriegsman, D. M., Deeg, D. J., & van Tilburg, W. (1995). The association of physical
health and depressive symptoms in the older population: Age and sex differences. Social Psy-
chiatry and Psychiatric Epidemiology, 3D, 32-38.
Bender, R. (1992). Yoga exercises and gentle movements for the elderly. In S. Harris, R. Harris, & W.
S. Harris (Eds.), Physical activity and sports: Practice, program and policy (Vol. II, pp.
344-371) Albany, NY: Center for the Study of Aging.
Biegel, L. (Ed.). (1984). Physical fitness and the older person: A guide to exercise for health care pro-
fessionals. Rockville, MD: Aspen.
Birren, J. E., Shapiro, H. B., & Miller, H. H. (1959). The effect of salicylate upon pain sensitivity.
Journal of Pharmacology and Experimental Therapeutics, 100, 67-71.
Boczkowski, J. (1984). Biofeedback training for the treatment of chronic pain in an elderly arthritic
female. Clinical Gerontology, 2, 39-46.
Bradley, L. A. (1989). Adherence with treatment regiments among adult rheumatoid arthritis pa-
tients: Current status and future directions. Arthritis Care and Research, 2, 533-539.
Bruce, M. L., Seeman, T. E., Merrill, S. S., & Blazer, D. G. (1994). The impact of depressive sympto-
matology on physical disability: MacArthur studies of successful aging. American Journal of
Public Health, 84, 1796-1799.
Butt. J. H, Barthel, J. S.. & Moore, R. A. (1988). Clinical spectrum ofthe upper gastrointestinal effects
of nonsteroidal anti-inflammatory drugs: Natural history, symptomatology and significance.
American Journal of Medicine, 84, 5-14.
Cadranel, J. F., Benhamou, Y., Zylberberg, P., Novello, P., Luciani, F., Valla, D., & Opolon, P. (1994).
Hypnotic relaxation: A new sedative tool for colonoscopy? Journal of Clinical Gastroenterol-
ogy, 18, 127-129.
Campora, E., Merlini, L., Pace, M., Bruzzone. M., Luzzani, M., Gottlieb. A.. & Rosso, R. (1991). The
incidence of narcotic induced emesis. Journal of Pain and Symptom Management, 6,
428-430.
Casten, R. J., Parmelee, P. A., Kleban, M. H., Lawton, M P., & Katz, I. R. (1995). The relationship
among anxiety, depression, and pain in a geriatric institutionalized sample. Pain, 61,
271-276.
Chapman, C. R. (1978). Pain: The perception of noxious events. In R. A. Sternbach (Ed.), The psy-
chology of pain (pp. 169-202). New York: Raven.
Chaves, J. F. (1994). Recent advances in the application of hypnosis to pain management. American
Journal of Clinical Hypnosis, 37, 117-129.
Cherny, N. I., & Popp, B. (1997). The management of cancer pain in elderly patients. In J. Lomranz
& D. I. Mostofsky (Eds.), Handbook of pain and aging (pp. 267-308). New York: Plenum.
Clark, W. c., & Mehl, L. (1973). Signal detection theory procedures are not equivalent when thermal
stimuli are judged. Journal of Experimental Psychology, 97,48-53.
Closs, S. J. (1994). Pain in elderly patients: A neglected phenomenon? Journal of Advanced Nurs-
ing, 19, 1072-1081.
Cohen-Mansfield. J.. & Marx, M. S. (1993). Pain and depression in the nursing home: Corroborating
results. Journal of Gerontology: Psychological Sciences, 48, 96-97.
Collins. G.. & Stone. L. A. (1966). Pain sensitivity. age and activity level in chronic schizophrenics
and in normals. British Journal of Psychiatry, 112. 33-35.
Corran, T. M., Helme, R. D.. & Gibson, S. J. (1993. August). Comparison of chronic pain experience
in young and elderly patients. Paper presented at the 7th World Congress on Pain, Paris.
Crook. J.. Rideout. E., & Browne, G. (1984). The prevalence of pain complaints in a general popula-
tion. Pain, 18,299-314.
Cutler, R. B., Fishbain, D. A., Rosomoff, R. S., & Rosomoff. H. 1. (1994). Outcomes in treatment of
pain in geriatric and younger age groups. Archives of Physical Medicine and Rehabilitation,
75,457-464.
Czirr, R., & Gallagher, D. (1983). Case report: Behavioral treatment of depression and somatic com-
plaints in rheumatoid arthritis. Clinical Gerontology, 2, 63-66.
Davis. G. C., Cortex, C.. & Rubin. B. R. (1990). Pain management in the older adult with rheuma-
toid arthritis or osteoarthritis. Arthritis Care and Research, 3, 127-131.
DeBenedittis, G., Panerai, A. A., & Villamira. M. A. (1989). Effects of hypnotic analgesia and hyp-
notizability on experimental ischemic pain. International Journal of Clinical Hypnosis, 37,
55-69.
Deyo, R. A.. Walsh, N. E.. Martin, D. C.. Schoenfield. 1. S., & Ramamurthy. S. (1990). A controlled
trial of transcutaneous electrical nerve stimulation (TENS) and exercise for chronic low back
pain. New England Journal of Medicine, 322. 1627-1634.
Dixhoorn. J. V., Duivenvoorden, H. J.• Pool. J., & Verhage, F. (1990). Psychic effects of physical train-
ing and relaxation therapy after myocardial infarction. Journal of Psychosomatic Research. 34,
327-337.
Domangue. B. B.• Margolis, C. G., Lieberman, D., Kaji. H. (1985). Biochemical correlates ofhyp-
noanalgesia in arthritic pain patients. Journal of Clinical Psychiatry, 46, 235-238.
Ettinger, A. B.. & Portenoy, R. K. (1988). The use of corticosteroids in the treatment of symptoms
associated with cancer. Journal of Pain and Symptom Management, 3, 99-103.
Ferrell. B. A. (1991). Pain management in elderly people. Journal of the American Geriatrics Soci-
ety, 39, 64-73.
Ferrell, B. A .• Ferrell, B. R., & Osterweil. D. (1990). Pain in the nursing home. Journal of the Amer-
ican Geriatrics Society, 38. 409-414.
Fiatarone, M. A., Marks, E. C.. Ryan. N. D., Meredith, C. N .. Lipsitz. L. A., & Evans. W. J. (1990).
High-intensity strength training in nonagenarians. Journal of the American Medical Associa-
tion, 263, 3029-3034.
Flatten. K.. Wilhite. B.. & Reyes-Watson. E. (1988). Exercise activities for the elderly. New York:
Springer.
Fordyce. W. E. (1976). Behavioral methods for chronic pain and illness. St. Louis. MO: Mosby.
Fordyce, W. E. (1986). Learning processes in pain. In R. A. Steinbach (Ed.). The psychology of pain
(2nd ed., pp. 49-65). New York: Raven.
Fordyce, W. E.• Fowler, R., Lehmann. J.• DeLateur, B., Sand P.. & Trieschamann. R. (1973). Oper-
ant conditioning in the treatment of chronic pain. Archives of Physical Medicine. 54,
399-408.
Fraser, J., & Kerr. J. R. (1993). Psychophysiological effects of back massage on elderly institutional
patients. Journal of Advanced Nursing, 18, 238-245.
Fridlund, B., Hogstedt, B., Lidell, E., & Larson. P. (1991). Recovery after myocardial infarction: Ef-
fects of a caring rehabilitation program. Scandinavian Journal of Caring Sciences, 5, 23-32.
Gagliese, 1., & Melzack, R. (1995. May). Age differences in the quality but not intensity of chronic
pain. Paper presented at the annual meeting of the Canadian Pain Society. Ottawa, Ontario.
Canada.
Gagliese. L.. & Melzack, R. (1997). The assessment of pain in the elderly. In J. Lomranz & D. 1.
Mostofsky (Eds.), Handbook of pain and aging (pp. 69-96). New York: Plenum.
Garfinkel, M. S .• Schumacher. H. R. Jr., Husain, A., Levy, M., & Reshetar, R. A. (1994). Evaluation of
a yoga based regimen for treatment of osteoarthritis of the hands. Journal of Rheumatology, 21,
2341-2343.
Pain Management 427
Garron, D. C., & Leavitt, F. (1979). Demographic and affective covariates of pain. Psychosomatic
Medicine, 41, 525-535.
Gibson, S. J., Katz, B., Corran, T. M., Farrell, M. J., & Helme, R. D. (1994). Pain in older persons. Dis-
ability and Rehabilitation, 16, 127-139.
Haanen, H. C., Hoenderdos, H. T., van Romunde, 1. K., Hop, W. C., Mallee, C., Terwiel, J. P., & Hek-
ster, G. B. (1991). Controlled trail of hypnotherapy in the treatment of refractory fibromyalgia.
Journal of Rheumatology. 18,72-75.
Hamburger, 1. (1982). Reduction of generalized aversive responding in a post-treatment cancer pa-
tient: Relaxation as an active coping skill. Journal of Behavior Therapy and Experimental Psy-
chiatry, 12,241-247.
Hardy, J. D., Wolff, H. G., & Goodell, H. (1943). The pain threshold in man. American Journal ofPsy-
chiatry, 99, 744-751.
Harkins, S. W., & Chapman, C. R. (1976). Detection and decision factors in pain perception in young
and elderly men. Pain, 2, 253-264.
Harkins, S. W., & Chapman, C. R. (1977a). Age and sex differences in pain perception. In D. J. An-
derson & B. Mathews (Eds.), Pain in the trigeminal region (pp. 435-441). Amsterdam: Elsevier.
Harkins, S. W., & Chapman, C. R. (1977b). The perception of induced dental pain in young and el-
derly women. Journal of Gerontology, 32, 428-435.
Harkins, S. W., Price, D. D., & Martelli, M. (1986). Effects of age on pain perception: Thermonoci-
ception. Journal of Gerontology, 41, 58-63.
Herning, M. M. (1993). Posture improvement in the frail elderly. In H. M. Perry, III, J. E. Morley, &
R. M. Coe (Eds.), Aging and musculoskeletal disorders: Concepts, diagnosis and treatment
(pp. 334-353). New York: Springer.
Herr, K. A., & Mobily, P. R. (1991). Complexities of pain assessment in the elderly. Clinical consid-
erations. Journal of Gerontological Nursing, 17,12-19.
Herr, K. A., Mobily, P. R., & Smith, C. (1993). Depression and the experience of chronic back pain:
A study ofrelated variables and age differences. Clinical Journal of Pain, 9, 104-114.
Hitchcock, L. S., Ferrell, B. R., & McCaffery, M. (1994). The experience of chronic nonmalignant
pain. Journal of Pain and Symptom Management, 9, 312-318.
Holroyd, J., & Hill, A. (1989). Pushing the limits of recovery: Hypnotherapy with a stroke patient.
International Journal of Clinical and Experimental Hypnosis, 37, 120-128.
Houston, K. (1993). An investigation of rocking as relaxation for the elderly. Geriatric Nursing, 14,
186-189.
Huskisson, E. C. (1974). Measurement of pain. Lancet. 2, 1127-1131.
Johnson, M. I., Ashton, C. H., & Thompson, J.w. (1991). An in-depth study of long-term users of
transcutaneous electrical nerve stimulation (TENS). Implications for clinical use of TENS.
Pain, 44, 221-229.
Johnson, M. I., Ashton, C. H., & Thompson, J.w. (1992). Long term use of transcutaneous electrical
nerve stimulation at Newcastle Pain Relief Clinic. Journal of the Royal Society of Medicine,
85, 267-268.
Kaiko, R. F., Wallenstein, S. 1., Rogers, A. G., Grabinski, P. Y., & Houde, R. W. (1982). Narcotics in
the elderly. Medical Clinics of North America, 66, 1079-1089.
Kanter, T. G. (1984). Peripherally-acting analgesics. In M. Kuhr & G. Pasternak, G. (Eds.), Analgesics:
Neurochemical, Behavioral and Clinical Perspectives (pp. 289-312). New York: Raven.
Kerlan, R. K. (Ed.). (1991). Clinics in sports medicine. Philadelphia: Saunders.
King, A. C., & Arena, J. G. (1984). Behavioral treatment of chronic cluster headache in a geriatric pa-
tient. Biofeedback and Self Regulation, 9, 201-108.
Kremer, E., Atkinson, J. H., & Ignelzi. R. J. (1981). Measurement of pain: Patient preference does not
confound pain measurement. Pain, 10, 241-249.
Kwentus, J. A., Harkins, S. w., Lignon, N., & Silverman, J. J. (1985). Current concepts of geriatric
pain and its treatment. Geriatrics, 40,48-54,57.
Lang, E. V., & Hamilton, D. (1994). Anodyne imagery: An alternative to IV sedation in interventional
radiology. AJR, American Journal of Roentgenology. 162,1221-1226.
Lehr, J., & Swanson, K. (1990). Fit, firm &- 50. Chelsea, MI: Lewis.
Linoff, M., & West, C. (1982). Relaxation training systematically combined with music: Theatment of
tension headaches in a geriatric patient. International Journal of Behavioral Geriatrics, 1,
11-16.
Magni, J., Schifano, F., & DeLeo, D. (1985). Pain as a symptom in elderly depressed patients: Rela-
tionship to diagnostic subgroups. European Archives of Psychiatry and Neurological Sciences,
235, 143-145.
Maniglia, R, Schwartz, A. B., & Moriber-Katz, S. (1988). Non-steroidal anti-inflammatory nephro-
toxicity. Annals of Clinical and Laboratory Science, 18, 240-252.
Manton, K G. (1997). Chronic morbidity and disability in the U.S. elderly populations: Recent
trends and population implications. In J. Lomranz & D.1. Mostofsky (Eds.), Handbook of pain
and aging (pp. 37-68). New York: Plenum.
Masters, J. C., Burish, T. G., Hollon, S. D., & Rimm, D. C. (1987). Behavior therapy: Techniques and
empirical findings (3rd ed.). San Diego, CA: Harcourt Brace Jovanovich.
McCracken, 1. M., Mosley, T. H., Plaud, J. J., Gross, R T., & Penzien, D. B. (1993, August). Age,
chronic pain and impairment: Results from two clinical samples. Paper presented at the 7th
World Congress on Pain, Paris.
McCullough, P. K (1991). Geriatric depression: Atypical presentations, hidden meanings. Geri-
atrics, 46, 72-76.
McIntosh, I. B. (1990). Psychological aspects influence the threshold of pain. Geriatric Medicine, 20,
37-41.
Meichenbaum, D. H. (1977). Cognitive-behavior modification. New York: Plenum.
Melding, P. S. (1995). Psychiatric aspects of chronic pain. In R Roy (Ed.), Chronic pain in old age:
An integrated psychosocial perspective (pp. 194-214). Toronto: University of Toronto Press.
Melding, P. S. (1997). Coping with pain in old age. In J. Lomranz & D. I. Mostofsky (Eds.), Handbook
of pain and aging (pp. 167-184). New York: Plenum.
Melzack, R (1975). The McGill Pain Questionnaire: Major properties and scoring methods. Pain,
1,277-299.
Melzack, R (1987). The short-form McGill Pain Questionnaire. Pain, 30, 191-197.
Melzack, R, & Katz, J. (1992). The McGill Pain Questionnaire: Appraisal and current status. In
D. C. Turk & R. Melzack (Eds.), Handbook of pain assessment (pp. 152-168). New York:
Guilford.
Meyer, C. 1., & Hawley, D. J. (1994). Characteristics of participants in water exercise programs com-
pared to patients in a rheumatic disease clinic. Arthritis Care and Research, 7, 85-89.
Middaugh, S. J., Levin, R B., Kee, W. G., Barchiesi, ED., & Roberts, J. M. (1988). Chronic pain: Its
treatment in geriatric and younger patients. Archives of Physical Medicine and Rehabilitation,
69,1021-1025.
Middaugh, S. J., Woods, S. E.. Kee, W. G., Harden, R N., & Peters, J. R. (1991). Biofeedback-
assisted relaxation training for the chronic pain patient. Biofeedback and Self Regulation,
16,361-377.
Moss, M. S., Lawton, M. P., & Glicksman, A. (1991). The role of pain in the last year of life of older
persons. Journal of Gerontology: Psychological Sciences, 46, P51-5 7.
Mumford, H. M. (1965). Pain perception threshold and adaptation of normal human teeth. Archives
of Graduate Biology, 10,957-968.
Nelson, 1., Taylor, E, Adams, M., & Parker, D. E. (1990). Improving pain management for hip frac-
tured elderly. Orthopaedic Nursing, 9, 79-82.
Notermans, S. L. H. (1966). Measurement ofthe pain threshold determined by electrical stimulation
and its clinical application. I: Methods and factors possibly influencing the pain threshold.
Neurology. 16, 1071-1086.
Onghena, P., & Van Houdenhove, B. (1992). Antidepressant-induced analgesia in chronic non-
malignant pain: A meta-analysis of 39 placebo-controlled studies. Pain, 49, 205-220.
Parmelee, P. A., Katz, I. R, & Lawton, M. P. (1991). The relation of pain to depression among insti-
tutionalized aged. Journal of Gerontology: Psychological Sciences, 46, P15-21.
Patterson, D. R, Everett, J. J., Burns, G. 1., & Marvin, J. A. (1992). Hypnosis for the treatment of burn
pain. Journal of Consulting and Clinical Psychology, 60, 713-717.
Portenoy, R K, & Farkash, A. (1988). Practical management of non-malignant pain in the elderly.
Geriatrics, 5, 29-47.
Portenoy, R K, Foley, K M., & Inturrisi, C. E. (1990). The nature of opioid responsiveness and its
implications for neuropathic pain: New hypotheses derived from studies of opioid infusions.
Pain, 43, 273-286.
Pain Management 429
Procacci, P., Della Corte, M., Zoppi, M., Romano, S., Maresca, M., & Voegelin, M. (1974). Pain
threshold measurement in man. In J. J. Bonica, P. Procacci, & C. Pagoni (Eds.), Recent ad-
vances on pain: Pathophysiology and clinical aspects (pp. 105-147). Springfield, IL: Thomas.
Puder, R. S. (1988). Age analysis of cognitive-behavioural group therapy for chronic pain outpa-
tients. Psychology and Aging, 3, 204-207.
Rasmussen, M. J., Hayes, D. 1., Vlietstra, R. E.. & Thorsteinsson, G. (1988). Can transcutaneous elec-
trical nerve stimulation be safely used in patients with permanent cardiac pacemakers? Mayo
Clinic Proceedings, 63,443-445.
Saxon, S. V., & Etten, M. J. (1984). Psychosocial rehabilitation programs for older adults. Spring-
field, IL: Thomas.
Schludermann, E., & Zubek, J. P. (1962). Effect of age on pain sensitivity. Perceptual and Motor
Skills, 14, 295-301.
Schumacher, G. A., Goodell, H., Hardy, J. D., & Wolff, H. G. (1940). Uniformity of pain threshold in
man. Science, 92, 110-112.
Schuster, J. M., & Goetz, K. 1. (1994). Pain. In C. E. Coffey & J. L. Cummings (Eds.), Textbook of geri-
atric neuropsychiatry (pp. 334-350). Washington, DC: American Psychiatric Press.
Scogin, F., Rickard, H. C., Keith, S., Wilson, J., & McElreath, L. (1992). Progressive and imaginal re-
laxation training for elderly persons with subjective anxiety. Psychology and Aging, 7,
419-424.
Sengstaken, E. A., & King, S. A. (1993). The problems of pain and its detection among geriatric nurs-
ing home residents. Journal of the American Geriatric Society, 41, 541-4.
Sherman, E. D., & Robillard, E. (1960). Sensitivity to pain in the aged. Canadian Medical Associa-
tion Journal, 83, 944-947.
Sherman, E. D., & Robillard, E. (1964). Sensitivity to pain in relationship to age. Journal of the
American Geriatric Society. 12, 1037-1044.
Sorkin, B. A., Rudy, T. E., Hanlon, R. B., Turk, D. C., & Stieg, R. 1. (1990). Chronic pain in old and
young patients: Differences appear less important than similarities. Journal of Gerontology:
Psychological Sciences, 45, P64-68.
Stern, M. J., Gorman, P. A., & Kaslow, L. (1983). The group counselling v. exercise therapy study: A
controlled intervention with subjects following myocardial infarction. Archives of Internal
Medicine, 143, 1719-1725.
Stewart, R. B., Blashfield, R., Hale, W. E., Moore, M. T., May, F. E., & Marks, R. G. (1991). Correlates
of Beck Depression Inventory scores in an ambulatory elderly population: Symptoms, dis-
eases, laboratory values, and medications. Journal of Family Practice, 32. 497-502.
Sykes, N. P. (1991). [Letter]. Oral naloxone in opioid associated constipation. Lancet, 337, 1475.
Thorsteinsson, G. (1987). Chronic pain: use of TENS in the elderly. Geriatrics, 42, 75-82.
Turk, D. C. & Meichenbaum, D. (1994). A cognitive-behavioural approach to pain management. In
P. D. Wall & R. Melzack (Eds.), Textbook of pain (pp. 1337-1348). Endinburgh: Churchill Liv-
ingstone.
Turk, D. C., Okifuji, A., & Scharff, 1. (1995). Chronic pain and depression: Role of perceived im-
pact and perceived control in different age cohorts. Pain, 61.93-101.
Van der Does, A. J., & Van Dyck, R., & Spijker, R. E. (1988). Hypnosis and pain in patients with se-
vere burns: A pilot study. Burns, Including Thermal Injury. 14.399-404.
Weinsten, E. J., & Au, P. K. (1991). Use of hypnosis before and during angioplasty. American Jour-
nal of Clinical Hypnosis, 34, 29-37.
Williams, A. K., & Schulz, R. (1988). Association of pain and physical dependency with depres-
sion in physically ill middle-aged and elderly persons. Physical Therapy. 68, 1226-1230.
Williamson, G. M., & Schulz, R. (1992). Pain, activity restriction and symptoms of depression
among community-residing elderly residents. Journal of Gerontology: Psychological Sciences.
47, P367-372.
Williamson, J. (1978). Depression in the elderly. Age and Aging, 7 (Suppl.), 35-40.
Wisocki, P. A., & Mosher, P. A. (1982). The elderly: An under-studied population in behavioral re-
search. International Journal of Behavior Geriatrics, 1, 5-11.
Wisocki, P. A., & Powers, C. B. (1997). Behavioral treatments for pain experienced by older adults.
In J. Lomranz & D. I. Mostofsky (Eds.), Handbook of pain and aging (pp. 365-382). New York:
Plenum.
Woodrow. K. M .• Friedman. G. D.• Siegalaub. A. B.. & Collen. M. F. (1972). Pain tolerance: Differ-
ences according to age. sex. and race. Psychosomatic Medicine. 34. 548-556.
Yates. P.• Dewar. A.. & Fentiman. B. (1995). Pain: The view of elderly people living in long-term res-
idential settings. Journal of Advanced Nursing. 21. 667-674.
Yehuda. S .• & Carasso. R. L. (1997). A brief history of pain perception and pain tolerance in aging.
In J. Lomranz & D. I. Mostofsky (Eds.). Handbook of pain and aging (pp. 19-35). New York:
Plenum.
Zoob. M. (1978). Differentiating the chest pain. Geriatrics. 33. 95-101.
CHAPTER 19
The Experience
of Bereavement
by Older Adults
PATRICIA A. WISOCKI
INTRODUCTION
Bereavement is generally a normal response to loss, an experience shared by all

ages and all cultures and even by a number of species (Averill, 1979). It is not
an experience unique to the oldest among us, but it probably happens most of-
ten and most regularly to them. For example, each year in the United States ap-
proximately 800,000 people lose a spouse (Murrell & Himmelfarb, 1989). Most
ofthese people are over age 60. LaRue, Dessonville, and Jarvik (1985) reported
that 51 % of women and 13.6% of men over the age of 65 have been widowed
at least once.
This chapter is organized around four primary areas. First, characteristics
of bereavement, with particular emphasis on how older adults (i.e., people over
the age of 60) differ in their response to loss from people younger than 60 will
be outlined. The literature on this topic is sparse but informative. Second, the
evidence for a relationship between bereavement and the physical and mental
health of elderly bereaved will be reviewed. The research is extensive on the
general topic of bereavement, but relatively little work has been done with the
elderly bereaved. Third, evidence for benefits of social support in mitigating the
negative effects of the experience of loss for older adults will be presented. And
fourth, suggestions for clinical interventions for the elderly when the pain of be-
reavement becomes too difficult to manage are considered. In addition, several
successful treatment strategies are described.
PATRICIA A. WISOCKI • Department of Psychology, University of Massachusetts, Amherst, Massa-

chusetts 01003.
431
432 Patricia A. Wisocki
CHARACI'ERISTICS OF BEREAVEMENT
In distinguishing between bereavement, grief, and mourning, Averill (1979)

points out that bereavement refers to the real or symbolic loss of a significant
object, which may be human or nonhuman, tangible or intangible. He considers
grief and mourning to be two distinct aspects of bereavement. Grief is the be-
havioral face of bereavement, that is, "a set of stereotyped physiological and
psychological reactions of biological origin" (p. 341), whereas mourning is the
social face, that is, "a conventional pattern of response dictated by the mores
and customs of society" (p. 341).
Bereavement is recognized as a process by most theorists, but there is dis-
agreement over whether it proceeds in an ordered sequence of stages, as origi-
nally suggested by Lindemann (1944) and later by Kubler-Ross (1970), or has
separate components which do not necessarily occur successively or in any
particular order (Bowlby, 1980; Bugen, 1977; Parkes, 1972). In stage theories,
grief is presumed to pass through a set of normal stages toward resolution.
Wortman and Silver (1987) have pointed out that stage theories have been built
upon Freud's (1917) concept that grievers must "work through" their losses,
and that those who show no grief are abnormal. They do not, however, report
evidence indicating that the bereaved who fail to show significant distress are
at risk for later pathology. Instead, they note that such individuals may become
the target of social criticism for failing to grieve correctly. Most proponents of
these theories indicate that bereaved people may not experience all stages and
that they may not follow the designated order, but missing a stage or experienc-
ing a stage out of order is often regarded as indicative of pathological grieving.
Theories in which separate components of grieving are postulated include
most of the emotional reactions described in the stage theories, but the stages
need not occur in a fixed order. The time limits vary per period and the inten-
sity experienced in each period may differ markedly as a function of individual
and environmental variables (Bugen. 1977).
Recognizing and accepting the arguments against stage theories, I have nev-
ertheless opted to describe bereavement in stages for the sake of convenience.
This description was taken from previous work by Averill and Wisocki (1981)
and Wisocki and Averill (1988).
STAGES OF BEREAVEMENT
Stage 1. Shock
The bereaved experiences a dazed sense of unreality or numbing that may

last several hours or several days, and he or she often reports feeling isolated
from the world.
Stage 2. Protest and Yearning
The bereaved recognizes the loss, but does not entirely accept it. He or she
feels intense pain and longing for the deceased and protests over the fact of loss
The Experience of Bereavement by Older Adults 433
by means of a variety of "searching" behaviors, including dreams about the

dead person, "finding" him or her in familiar places, hallucinations, and so
forth. This is also a time of agitation, heightened physiological arousal, and rest-
lessness, sometimes alternating with a feeling of deceleration. The bereaved is
preoccupied with memories of the lost person and focuses attention on those
aspects of the environment that were associated with past pleasures experi-
enced with the individual. This stage typically lasts for several months.
Stage 3. Disorganization and Despair
In this stage the bereaved accepts the fact of the loss and abandons attempts
to recover the lost person, but continues to pine for the deceased. The bereaved
commonly experiences apathy, withdrawal, loss of energy and despondency, a
loss of sexual interest, poor socialization. diminished appetite, sleep distur-
bances. and other behavioral and somatic problems. The bereaved may experi-
ence conflicting emotions and moods. such as despair, hostility, shame, guilt,
anger, and irritability. This stage is the most enduring, complex, and difficult
phase of the grief process, often lasting a year or more.
Stage 4. Detachment, Reorganization, and Recovery
Characteristics of the previous stage are ultimately relieved when the be-
reaved develops new ways of perceiving and thinking about the world and his
or her place in it. A person regains hope and confidence in him or herself and
is able to enjoy life again. Most often, this involves establishment of new roles,
relationships, and sense of purpose in life. It is not unusual for a person to
grieve for several years before a relatively adequate readjustment occurs. Feel-
ings of grief may be triggered continuously by holidays and dates, which mark
meaningful events for the bereaved.
GRIEF REACTIONS AMONG OLDER ADULTS
Although there has been little work comparing or differentiating ways older
and younger men and women respond to bereavement, several characteristic re-
actions have been described for older adults. First, the affective experience of
grief is more subdued or "flat," and it is often more diffuse and obscured. Al-
though some have suggested that this quality is an indication that older adults
are not as pained by their losses as younger adults are, Skelskie (1975) has pro-
posed that such flattened affect may be a sign of inhibited grief or depression, or
that it may signal the relinquishing of an interest in life. Burnside (1969) has cau-
tioned that this characteristic pattern may lead to a misdiagnosis of organic brain
syndrome. Second, there are more likely to be complaints of a sense of ina-
dequacy, loss of purpose in life, and an unwillingness to "go on" without the
deceased. Third, some grief responses may be exaggerated among older adult
bereaved individuals, including apathy, self-isolation, and idealization of the
deceased (ef. Ball, 1976-1977; Heyman & Gianturco, 1973; Parkes, 1964; Skel-
skie, 1975; Stern, Williams, & Prados, 1951). Fourth, older bereaved people are
more likely to hallllcinate (Le., "see" or "hear") the deceased person (Rees,
1971), a process which has been associated with long happy marriages.
Younger widows have significantly stronger grief reactions than older wid-
ows, show greater irritability if the death of a spouse was sudden rather than
prolonged, and are more restless (Ball. 1976-1977). Maddison (1968) believed
that younger widows were at greater risk for high mortality rates following be-
reavement than older widows, a finding that was also related to existing finan-
cial problems, number of dependent children, preexisting problems with the
marriage, multiple crises, problems with the spouse's family. lack of support
from family or professionals, and personal problems of the widow herself.
Younger bereaved are more likely to have health problems following the loss of
a spouse (Maddison & Viola, 1968), higher mortality rates (Kraus & Lilienfeld,
1959), an increase in psychological difficulties (Parkes, 1964), and more sleep
disturbances (Gorer, 1965) than older adults.
These descriptions seem to suggest that the older bereaved person is bet-
ter adjusted to the experience of loss in comparison with the younger be-
reaved. Not everyone agrees, however. Stern and colleagues (1951) reported
that grief reactions of older bereaved in their sample (who were between the
ages of 53 and 70) included a greater preponderance of somatic illnesses,
such as pain, gastrointestinal problems, and sleep disorders than the younger
bereaved. Bettis and Scott (1981) have also stated that these problems are
more severe and more long-lasting for the older bereaved person than the
younger.
A longitudinal study by Sanders (1981) comparing bereavement outcomes
of older and younger widowed individuals determined that under certain con-
ditions the older group of bereaved (Le., persons over age 65) had more persis-
tent problems in adjustment than the younger group (Le., people under age 63),
compared with matched controls who were not bereaved. Sanders found that
duration of bereavement was differentially related to symptomatology and in-
tensity of grief for the two age groups. The younger widowed group responded
initially with greater shock, confusion, guilt, and anxiety, but they were able to
adjust fairly quickly. The older bereaved initially manifested diminished grief
responses, but their reactions became more powerful as time passed, even up to
two years after the loss. On the Grief Experience Inventory, the younger be-
reaved obtained higher scores on the element of guilt, while the older bereaved
scored higher on the denial element and on measures of social isolation, deper-
sonalization, death anxiety, and loss of vigor.
Results from the Sanders (1981) study are interesting, in that they point out
the painful progression of grief for the older adult and they indicate the impor-
tance of taking measures as time passes after a loss. Thus, while preponderance
of data suggest that younger bereaved are at higher risk for both physical and
mental health problems than older bereaved, the distress and symptomatology
experienced by elderly bereaved are, nonetheless, disturbing and often debili-
tating to their health. Research on the health effects of bereavement are ex-
plored in the next section.
EFFECTS OF BEREAVEMENT ON
WELL-BEING OF OLDER ADULTS
Mortality and Morbidity Effects
According to excellent reviews by Stroebe and Stroebe (1987) and Oster-

weis, Solomon, and Green (1984), epidemiological evidence from a variety of
sources demonstrated an increase in mortality rates for the recently bereaved
who experienced spousal loss, although conclusions from the evidence must be
drawn carefully because of a number of methodological problems in the various
data collection processes described in these studies. These reviews contain de-
tailed critiques of the data and are not repeated here.
In studying widows and widowers of all ages, Helsing, Szklo, and Com-
stock (1981) have noted increases in deaths from suicide, accidents, cardiovas-
cular disease, and some infectious diseases among widowers and an increase in
the risk of death from cirrhosis of the liver among widows. Glick. Weiss, and
Parkes (1974) found an increase in hospitalization among the widowed within
a year after the loss of a spouse, but only widowers demonstrated significantly
more physical health problems. Clayton (1979) reported similar findings in the
rate of hospitalization, but only among the young widowed sample. She did not
find differences in the number of reported physical problems between those
who were married and those who were widowed.
When older adults were specifically studied, however, results were sur-
prising. One might expect older bereaved people to be more vulnerable to the
detrimental health effects of bereavement because they initially are more likely
to be in poor health. As Stroebe and Stroebe (1987) point out, "the negative
health impact of bereavement is generally attributed to the fact that it aggravates
or accelerates existing health problems" (p. 185). The bulk of the evidence in-
dicates that it is the younger bereaved who suffer greater health deterioration.
For example, Heyman and Gianturco (1973) found a small increase in depres-
sive symptomatology in older widowed women, but no change in health,
leisure activities, or anxiety. Norris and Stanley (1987) likewise found no rela-
tionship between bereavement and health status, but did find that health sta-
tus was related to amount of stress in the family prior to occurrence of death
and after the death, only if there had been no stress in the family preceding the
death. Murrell, Himmelfarb, and Phifer (1988) also reported that, when health
status before bereavement was taken into account, there was no relationship be-
tween bereavement and self-reported health, nor between bereavement and
subsequent death, health problems, or use of medical services by the elderly
men and women who participated in their study. Other investigators concur
with these findings (Avis, Brambilla, Vass, & McKinlay, 1991; Wolinski & John-
son, 1992). Ferraro (1985) also found that elderly bereaved perceived their
health as poorer shortly after loss, but not on a long-term basis.
Thompson, Breckenridge, Gallagher, and Peterson (1984), however, be-
lieve that bereavement has more serious health effects on the elderly than
these data appear to indicate. They found that, among their sample of 212
widowed adults between the ages of 55 and 83, recently bereaved more often
reported a worsening of existing illnesses, development of new illnesses, be-

ginning a new medication, greater use of medication, and poorer health rat-
ings than adults in the control group. There were no differences between
groups on number of visits to physicians or hospitalizations. Although re-
cently bereaved men did not report greater morbidity than women in the sam-
ple, there were more deaths among them one year after loss of a spouse, and
there were more deaths among bereaved than among control group partici-
pants. Thompson and colleagues (1984) caution that bereaved men may have
underestimated their health problems at the time of the study.
Avis and colleagues (1991) also found that recent bereavement was associ-
ated with increased use of prescription medicine; Wolinski and Johnson (1992)
reported that it was linked to a greater probability of being placed in a nursing
home. Most seriously, Mendes de Leon, Kasl, and Jacobs (1993) provided a
weak but positive association between widowhood and mortality in the first
6 months after spousal death for a group of elderly bereaved. This effect was
most pronounced for widows between the ages of 65 and 74.
Findings about health consequences of bereavement are complicated by a
number of factors pertinent to older adults. We know, for instance, that mortal-
ity rates are affected by changes in residence to nursing homes, retirement
homes, and institutions (already indicators of poor health), and solitary living
(Morse & Wisocki, 1991). Remarriage seems to make a difference in the mortal-
ity rates of widowed men, but not of widowed women (Osterweis et a1., 1984).
Following a death, there are generally marked increases in the consumption of
tobacco, alcohol, and drugs (Maddison & Viola, 1968), mostly among people
who had used these substances earlier. Emotional stress in response to loss has
been implicated in deaths from congestive heart failure (Chambers & Reiser,
1953) and essential hypertension (Wiener, Gerber, Battine, & Arkin, 1975). In a
study of death occurrences during stressful times Engel (1961) reported that
half his sample of people died immediately after the death of a person close to
them and an additional 43% died within sixteen days after the death of some-
one close. Engel related the majority of these deaths, however, to cardiac arrest
in persons with cardiovascular disease, not to bereavement per se.
Another stress factor that may contribute to the bereaved person's health
status is related to the demands associated with caring for a relative who is ill,
dependent, or dying. Evidence suggests that caregivers worry often about fi-
nances and the adequacy of available help; they reduce their participation in
social and recreational events; and they frequently experience a great deal of
stress in family relationships (e.g. Canton, 1983; Poulshock & Deimling, 1984).
As Harlow, Goldberg, and Comstock (1991b) determined, depression scores ofa
group of elderly men and women prior to widowhood were inversely related
to the spouse's health status, indicating perhaps that bereavement begins some-
what before actual death occurs.
It is commonly assumed that opportunity to grieve prior to the loss may
ease the impact of the loss and facilitate long-term recovery for the bereaved
person. This process, called anticipatory grief (Lindemann, 1944), has been ex-
amined in a few studies in which suddenness of death was a major variable.
Clayton (1979) and Parkes (1972) both found that young widows grieve less
and remarry sooner following an anticipated death, as opposed to a sudden
death. Lundin (1984) found that sudden death from acute illness was associ-
ated with a significant increase in sick days on the part of the bereaved,
whereas expected death from chronic illness was not significantly related to
the number of sick days.
For the elderly, however, it appears the opposite is true. Gerber, Rusalem,
Hannon, Battin, and Arkin (1975) found that elderly widows had a better prog-
nosis if their husbands died suddenly rather than after a lingering illness. Sim-
ilar results were obtained by Vachon and colleagues (1977), who compared
widows of cancer patients with widows of men who suffered from chronic car-
diovascular disease. Deaths of the cancer patients were generally anticipated,
whereas the deaths ofthe patients with cardiovascular disease were sudden, al-
though not completely unexpected. One to two months after their loss, 38% of
the widows whose husbands had died of cancer reported that they felt worse
than they did immediately after the death. Twenty-three percent of the widows
of the men who had died of cardiovascular disease reported feeling worse dur-
ing that same time period, which is a statistically significant difference. Cancer
widows were also more likely to feel that they were in poor health following the
death of their husbands than the other widows.
Additional evidence is provided by Hill, Thompson, and Gallagher (1988),
who found that elderly bereaved women who had anticipated or spontaneously
rehearsed for their loss by discussing funeral arrangements, financial security,
feelings about being left behind, and prospects for the future if one's spouse
died before they did, were more poorly adjusted after their loss, reported sig-
nificantly more health problems, and tended to show greater levels of depres-
sion than those widows who had not engaged in spontaneous rehearsal
strategies. These investigators also found no relationship between expectancy
of death and the subsequent adjustment to bereavement.
Averill and Wisocki (1981) have offered several reasons why anticipated
loss, as compared with sudden loss, should be more debilitating for older
adults than for younger adults. The first reason is that death seldom comes as
a complete surprise to the elderly. They frequently experience deaths of their
friends and family members and receive several reminders of their own vul-
nerability to mortality. Consequently, some of the value a forewarning might
provide to the young may be superfluous to the elderly. Second, anticipation
of a threatening event can be a potent source of stress in its own right. Know-
ing that a spouse will die within a limited time period can add to the stress of
bereavement without necessarily conferring compensating benefits. This is es-
pecially true if the surviving spouse is suffering from chronic ill health or
some other preexisting condition that might be worsened by the stress of car-
ing for a dying partner.
It is important to recognize, however, that caring for a dying partner may
also provide purpose and satisfaction to the lives of some elderly. Caregiving
may be the primary source of social support for the caregiving partner. Thus,
ironically, the third reason why an anticipated bereavement may be particularly
difficult for the elderly, is that, with death of a spouse, the caregiving partner
loses these positive attributions and affiliations. The fourth reason is related to
the third. It is difficult for a person to make personal sacrifices that are often
demanded by a dying spouse without experiencing some ambivalence. This is
especially true if the spouse's illness has progressed through a series of remis-
sions, increasing risk of premature detachment. An ambivalent relationship
prior to death of a partner is frequently cited as an etiological factor in patho-
logical grief (Aldrich, 1974; Parkes, 1972).
Mental Health Effects
Numerous studies of stressful life events and life change events repeatedly
confirm loss as a powerful predictor of mental disorder (e.g., Dohrenwend &
Dohrenwend, 1974; Rahe, 1979). In an extensive review of the health risks of
the bereaved, Stroebe and Stroebe (1987), reported overwhelming support for
the idea that bereavement may be a cause of mental illness. Only one study re-
ported dissenting findings. That study was done by Clayton (1979), who stud-
ied 109 widowed people and found that both psychiatric consultation and
hospitalization were rare following the death of a spouse.
Although the bulk of these studies was conducted with younger adults, it
appears that the bereaved older adult is also likely to experience high rates of
psychological symptomatology. For example, Richards and McCallum (1979)
reported rates of diagnosed depressive disorder or severe psychological distress
in 25% to 33% of the elderly bereaved in their sample population within the
first year of bereavement. Jacobs, Melson, and Zisook (1987) reported that 10%
to 20% of the 800,000 people in the United States who become widows or wid-
owers suffered from severe depression during the first year of bereavement.
Carey (1977) not only found that self-reported depression occurred significantly
more often among the widowed than among the married. but it was still mea-
surable as long as 13 to 16 months after the loss. In cases where a spouse com-
mitted suicide, elderly bereaved were significantly more anxious than their
counterparts whose spouses died "natural deaths," but did not differ on other
measures of psychological distress; both groups of bereaved elderly demon-
strated significantly higher scores on measures of depression and general psy-
chopathology (Farberow, Gallagher, Gilewski, & Thompson, 1987).
Along with depression, the elderly bereaved experience problems with sleep,
social support, self-esteem, and impaired functioning (Pasternak et al., 1994).
Progression of bereavement over an extended time has been examined by
several researchers and the findings illuminate important aspects about the psy-
chological healing process for elderly bereaved. In a series of studies by Clayton
and her colleagues (Bomstein, Clayton, Halikas, Maurice, & Robins, 1973; Clay-
ton, Halikas, & Maurice, 1972; Clayton, Herjanic, Murphy, & Woodruff, 1974),
35% of their sample of older widows and widowers (mean age 61.5) showed
signs of depression at 1 month after their losses, 25% at 4 months, and 17% up
to a year after the loss. Harlow, Goldberg, and Comstock (1991a) reported simi-
lar percentages with their sample of elderly bereaved women. They found that
17.5% of the bereaved show~d a higher percentage rate of depressive symptoms
after the first year of widowhood. For the majority of the population studied,
depressive reactions peaked at 6 months after the loss and returned to baseline
levels after the first year, a finding which led them and other researchers (e.g ..
Murrell & Himmelfarb, 1989) to conclude that bereavement does not pose a se-
rious threat to mental health among the elderly.
That conclusion was challenged by Mendes De Leon, Kasl, and Jacobs
(1994), who, as part of a prospective study, conducted a detailed and extensive
examination of the course of depressive symptomatology during the bereave-
ment of 139 elderly widowed men and women between the ages of 65 and 99.
They described a 75% increase in depression scores during the first year of be-
reavement, which returned to prewidowhood levels for most people by the sec-
ond year after the loss. They did not, however, find this pattern to be true for
younger female members of the sample (i.e., those between 65 and 74). For
these widows, levels of depressive symptoms did not decline as much after the
initial increase and remained elevated long after the first year. In fact, their
symptoms persisted into the second and third years following spousal loss.
Prevalence rates calculated over the years of the study indicated that 37.5% of
older bereaved adults experienced high depressive symptomatology during the
first year of bereavement and 16% of the sample were bereaved for more than
1 year. Mendes de Leon and his colleagues concluded from these data that
many older bereaved adults, especially those in the lower register of senior cit-
izenship, "experienced clinically significant increases in depressive sympto-
matology well beyond the normal duration of the grief process, and that many
of these indeed are likely to suffer from depressive disorder" (p. 622).
Interestingly in this study, the acutely bereaved reported symptoms of dis-
turbed affect, but not symptoms relating to negative self-appraisal, which the
authors proposed may be reflective of the normal manifestation of grief and
may provide a useful diagnostic distinction between grief and depression. In-
deed, Mendes De Leon and colleagues (1994) compared elderly subjects who
had elevated depression scores 1 year after spousal death and nonwidowed el-
derly subjects who also had high depression scores. They found that the wid-
owed group had levels of negative appraisals that were almost as high as those
of the persistently depressed nonwidowed. By contrast, very few of the recently
bereaved endorsed the negative appraisal symptoms. These findings led the re-
searchers to conclude that elderly bereaved with persistent elevations of de-
pressive symptomatology after the first year of widowhood may require
professional clinical treatment. Information from McHorney and Mor (1988) in-
dicating that bereaved subjects who were classified as depressed increased their
contact with physicians, in comparison with the bereaved who were not de-
pressed, lends additional support to this conclusion.
Pasternak and her colleagues (1994) took this notion a step further by iden-
tifying a clinically subsyndromal depressed group of elderly bereaved and com-
paring them with a matched group who were not depressed and a group who
were neither depressed nor bereaved. Subjects (average age 68 years) were rated
on measures of general functioning, depressive symptoms, sleep disturbances,
medical condition, social support, social rhythm stability, and grief intensity
every 6 months for 2 years after loss of spouses in the first two groups. De-
pressed participants consistently demonstrated greater impairments than the
other two sets of participants, even after 2 years. They showed continued in-
tense grieving and impaired sleep quality at 18 months after the loss, lower so-
cial support, poor self-esteem, and impaired life functioning 1 to 2 years later.
Stability of social rhythms was not impaired, however (a finding that the au-
thors suggest may have protected those subsyndromally depressed bereaved
from developing more serious forms of depression). All of the bereaved elderly
had increased medical problems, as compared with control subjects.
It appears, then, that the elderly bereaved experience multiple psychologi-
cal problems connected to the grief experience. They are particularly vulnera-
ble to depressive symptomatology, which may persist for several years after the
death of a spouse. Depression in cases of bereavement, however, is qualitatively
different from chronic clinical depression for elderly men and women. Thus,
bereavement does not appear to be a primary etiological factor in most cases of
depression in the elderly.
SOCIAL SUPPORT AS A FACfOR

IN BEREAVEMENT
In addition to the often painful loss of the person himself or herself, death
of a loved one often eliminates an important source of interaction and it may
eliminate one's role in society as well. When one's identity has been defined by
the relationship to the deceased (e.g., as husband or wife), role loss is a major
source of distress and depression in its own right. Such loss may help explain
why many elderly bereaved report a sense of meaninglessness and lack of pur-
pose after the death of a spouse, not to mention a sense of social isolation, lone-
liness, or apathy long after the bereavement process has ended. The survivor
may be required to move to a smaller, more manageable residence; children and
other relatives may be living at a distance and thus be unable to provide con-
tinuing social support; financial resources may be inadequate to sustain a com-
fortable life style; a person may lack job skills, driving skills, and even
self-management skills. For example, many elderly widows have never had ex-
perience in managing money and thus are ill prepared to do it. Many elderly
widowers have never had experience preparing a meal or maintaining a house,
and thus are lacking adequate survival skills.
Perhaps because the social losses are so great, the social network may take
on greater importance for people at the time of bereavement. Certainly, results
from a number of studies suggest that social factors playa strong role in not
only alleviating the stress of the loss (Schwarzer, 1992) but in helping to ame-
liorate postbereavement depression in the elderly (Norris & Murrell, 1990;
Siegel & Kuykendall, 1990).
Bowling (1988-1989) followed 503 widowed elderly for 6 years after loss of
their spouses and found that the death rate for widowers over 75 years of age
was significantly higher than for the same-aged men in the general population.
Multivariate analyses showed that, in addition to being a male over 75 years of
age, the most powerful discrliminating variables independently associated with
mor.tality were a low happiness rating given by the interviewer, high social
class, and having no one to telephone. Bowling suggested that social contact
and a happier disposition may have modifying effects on the stress of bereave-
ment and the risk factors associated with subsequent mortality.
From a large epidemiological study, Goldberg, Comstock, and Harlow

(1988) interviewed 128 elderly widows (6 months after spousal loss) who had
in the original baseline interview reported specifically that they did not need
help for an emotional problem and who had completed questionnaires assess-
ing number of people in their social network and quality of the interactions. At
the time of the second interview participants were again asked if they needed
help with an emotional problem since becoming widowed. Nearly 22% re-
sponded affirmatively to the question. In a series of multiple logistic regression
analyses, the authors examined the effects of social network variables on the
expressed need for help and found that three were significant. First, they
found that size of the network was a significant factor in a lack of need for
emotional counseling. Widows with networks smaller than 10 people were at
greater risk. A similar finding was also reported by Dimond, Lund, and Caserta
(1987), who determined that size ofthe social network, perceived closeness to
the members of the network, and the quality of the interaction were signifi-
cantly related to coping behavior, lower scores on the depression measure, and
higher life satisfaction 2 years after spousal loss for 192 elderly bereaved men
and women.
The second significant variable from the work of Goldberg and her col-
leagues (1988) is that number of friends seemed more important than size of
one's family. Widows with four or more friends with whom they kept in touch
were less likely to feel the need for emotional counseling than those with fewer
friends. This finding is similar to the conclusion reached by Arling (1976b),
who compared various sources of social support, such as family members,
friends, and neighbors on their effect on the morale of elderly widowed. Arling
found that contact with friends and neighbors was clearly related to a reduction
in loneliness and worry, while contact with family members, especially chil-
dren, did little to elevate morale.
Goldberg and colleagues' (1988) findings on the value of children to the
widow are different from conclusions reached by Arling (1976b). Goldberg and
her colleagues found that widows who, at baseline, had reported a very close re-
lationship to their children, were less likely to have a need for help during the
bereavement process than were either those widows who had no children or
who had a low level of closeness to their children. This finding is also sup-
ported by Lopata's (1979) work, in which it was found that the widow's chil-
dren provided more service and emotional support than her friends. It is
possible, however, that participants in Goldberg and colleagues' (1988) study
were stronger because they had the security of knowing about the positive qual-
ity of their relationship to their children, but that fact mayor may not have been
related to the importance of developing other relationships with nonfamily
members after the loss of the spouse. Indeed, research has consistently shown
benefits from friendship networks (cf. review by Ferraro, 1984), whereas re-
search on the family has not shown such benefits and family-based relation-
ships have usually been regarded as providing neutral or even negative effects
(cf. review in Mutran & Reitzes, 1984). Results of a number of studies in which
family and friends have been compared as sources of support (e.g., Arling,
1976a; Roberto & Scott, 1986) have indicated that support from friends is more
important to the widowed.
This finding contradicts common wisdom. which suggests that bereave-

ment demands a pulling together of the family resources; after an initial period
of condolence. friends often tend to stay away to allow the bereaved time to
share the grief experience within the family. Research findings. however. inti-
mate that a supply of friends is essential in easing the pain of bereavement. So-
cial contacts in various forms. including phone calls. personal visits. and even
letters are beneficial for the elderly bereaved.
Lack of a network of social acquaintances may have the same deleterious
effect as a lack of good health practices. Those elderly who have lost friends
through death or new residential placements. or those who have lost them by
exclusive focus on family over a long period of time. or those who never had
many friends to begin with. may find it particularly difficult to reenter a social
world after the death of a long-time companion.
Worden (1982) feels so strongly about the importance of social support for
the bereaved that he has stated that the role of mental health professionals in
grief therapy is to provide a substitute for religious and family institutions that
have stopped providing necessary support to the bereaved in the culture.
THERAPY FOR THE ELDERLY BEREAVED

Grief is a normal response to loss and not a form of pathology. It is a com-
plex experience. the origins of which may be found in the biological. psycho-
logical, and sociocultural history of an individual. Thus. as has been stated
elsewhere (Averill & Wisocki. 1981). some of the components of grief. such as
protest. search. and depression of activity may reflect biological adaptations. ei-
ther directly or indirectly. Other components may be the result of psychological
factors. such as extinction of habits that have been built up over many years of
living with another person. Finally. still other components may reflect social
privileges and responsibilities. Any therapeutic regimen that seeks to alleviate
the suffering of the bereaved must be sensitive to these historical causes. as well
as to the aspects of the current situation that together help determine the nature.
severity. and duration of the entire grief experience. It is not the goal of therapy
to eliminate grief. but to understand it and alleviate some of its pain.
The various components of grief cannot be attributed to any single cause
and thus cannot be alleviated by any single procedure. As has been stated else-
where (Wisocki & Averill. 1988). goals should be established and intervention
procedures should be selected depending on the component reactions that are
presenting difficulties. For instance. possible categories of goals may include
physiological concerns, such as somatic symptoms. insomnia. headaches. com-
pliance to medical regimen!;. proper nutrition. and self-care activities; subjec-
tive (private) events, such as devaluative self-statements. disturbing thoughts
about taking one's life in order to join the deceased. self-blaming statements
about ways one could have kept the deceased alive. and so on; overt behaviors,
including behavioral excesses commonly occurring during bereavement. such
as alcohol consumption or over-medication. compulsions. and avoidance reac-
tions; interpersonal relationships. such as reducing isolation. increasing social
contacts, assertive behaviors when necessary; and environmental supports,

which may involve changing environmental structures to support or facilitate
therapeutic gains.
Occasionally grieving has pathological aspects. For instance, a person may
openly grieve for "too long," a time determined by social custom, but generally
meaning more than a year. At times a person seems to devote too much energy
and too many resources to celebrating the deceased, such as turning a room in
a house into a "shrine" or setting a place at the dining table each day for the de-
ceased person. These prolonged grief experiences are not only troubling in and
of themselves, but they may also lead to health-threatening behaviors, such as
refusal to eat, withdrawal from companionship, depression, and so forth.
The symptoms of pathological grief have been listed by Wahl (1970) as pro-
found feelings of irrational despair and hopelessness; an inability to accept or
deal with feelings of ambivalence toward the deceased person; loss of self-esteem;
self-blame for the death; an inability to proffer affection to others; loss of interest
in planning for the future; protracted apathy, irritability, or hyperactivity without
appropriate affect. This is only a partial list, but it illustrates the commonality of
symptoms between normal and pathological grieving. These symptoms become
pathological only if they are unduly prolonged or if they are expressed in such a
way as to lead to other forms of serious maladaptive behavior.
Worden (1982) believes that pathological grief occurs when four grieving
tasks have not been completed: accepting the reality of the loss, experiencing the
pain of the loss, adjusting to an environment in which the deceased is not pres-
ent, and withdrawing emotional energy and reinvesting it in another relation-
ship. The focus in therapy is on the resolution of these tasks, which are achieved
by getting the client to talk to the deceased. Methods for accomplishing this goal
include role playing, linking objects and photos (Le., touching special tokens,
clothing, pictures, etc. ofthe deceased as a way of stimulating memories), and
the empty-chair technique. Worden also relies heavily on the therapeutic rela-
tionship to provide the necessary social support for the bereaved.
Volkan (1975) has developed a short-term model of treatment called "re-
grief therapy," in which the bereaved undergoes three processes: demarcation,
externalization, and reorganization, all designed to separate the bereaved per-
son from the deceased. The person is first encouraged to relive the orginalloss
experience by recounting or behaviorally tracing the details of it and abreacting.
Confrontation is a technique central to this process and ultimately serves to di-
rect the bereaved's energies toward new objects.
Melges and DeMaso (1980) have developed "grief resolution therapy,"
based on use of abreactive processes, for removal of elements they feel prevent
the resolution of grief.
There are several therapies for pathological bereavement that employ tech-
niques based primarily on behavior therapy. For example, Kleber and Brom
(1985) use relaxation, desensitization, and hypnotic imagery to have the be-
reaved client gradually confront the relevant aspects of his or her loss. They
also work with clients in a psychodynamic framework to help them discover
and solve intrapsychic conflicts related to loss. Lieberman (1978) has described
a similar approach, using systematic desensitization and implosion, a therapy
model that he describes as "forced mourning." Ramsay (1977) recommends

flooding as the most effective model of therapy because it involves a confronta-
tion with the stimuli associated with the loss and elicits the grief response. In
using the flooding procedure, considerable time is devoted to developing de-
tails of the client's relationship to the deceased. Guided imagery is also used to
have the client re-create the moment of parting to allow expression of unstated
thoughts and feelings.
Exposure to stimuli associated with loss is regarded by many as the critical
ingredient in overcoming pathological grieving. Research efforts to demonstrate
the importance of this factor have produced interesting results. Mawson. Marks.
Ramm, and Stern (1981) compared a guided mourning and exposure technique
with anti exposure instructions to avoid contact with distressing situations re-
lating to subjects' bereavement. They found that. after 1 month of treatment, sub-
jects in the exposure condition showed less avoidance of bereavement cues and
scored better on the Texas Inventory of Grief than the other group. On most other
measures, however, the groups improved equally. Sireling, Cohen, and Marks
(1988) attempted a replication of this study with an increase in number of sub-
jects and treatment sessions, the addition of more systematic advice, support,
and help with relationships, work, and recreational activities, additional affec-
tive and cognitive cues, and more assessments. They reported similar results,
again favoring the guided mourning and exposure condition.
Specific attempts to provide therapy for bereaved who are elderly have
been relatively rare. Probably the most extensive effort directed to alleviation of
bereavement-associated pain for the older adult going through a normal griev-
ing process is organized around the use of support groups. such as the widow-
to-widow programs and othJ;lr social networks (d. Walker, McBride, & Vachon,
1977). These groups exemplify the philosophy that grieving people are helped
best by others who have shared the experience. And, as we have seen earlier,
the social supportive aspects of group involvement are therapeutic in and of
themselves for the older bereaved person.
Gerber, Wiener, Battin, and Arkin (1975) conducted a longitudinal investi-
gation of a sample of elderly bereaved to evaluate the effects of unsolicited cri-
sis intervention on medical outcomes. One hundred sixteen subjects were
assigned to a treatment group; 53 were assigned to the nontreatment control
group. Subjects in the treatment group were given support for the affective as-
pects of the grief response, helped to increase their participation in social ac-
tivities with friends and family members, and helped with practical matters of
legal, financial, and household concerns. Interviews were conducted at the
homes of the subjects or by telephone. After 6 months intervention was termi-
nated. Evaluations were conducted at 3,5,8, and 15 months after the loss. Sub-
jects in the treatment group reported fewer drug prescriptions, fewer
consultations with physicians, and fewer experiences of feeling ill. These find-
ings confirmed the health benefits of the therapy and support the incorporation
of social and practical elements in an intervention with elderly bereaved.
For the most part, the elderly bereaved seem to benefit from suggestions
about restructuring their environment, increasing social contact, and maintain-
ing adaptive behaviors. For specific problems associated with the grieving
process, the bereaved might be trained in specific stress-relieving strategies,
such as relaxation to assist in sleep induction, self-reinforcement for a more

positive attitude, thought stopping about guilt, fears about the future, and so on,
and desensitization to avoidance behaviors. Use of such procedures does not
mean that the elderly person should not be permitted to express his or her grief
openly. All therapeutic models encourage this expression to varying degrees.
As Wisocki and Averill (1988) have pointed out previously, the therapist
working with the elderly bereaved should be prepared to extend his or her services
in areas which are not strictly psychological in nature. Some of the most serious
needs of an elderly client may be economical. The therapist may have to work
with the client to establish a budget, open a bank account, pay bills, get a driver's
license, and other mundane matters. At the minimum the therapist should be
aware of relevant support services available within the client's local community
and be able to serve as a catalyst to ensure that the client utilizes those services.
SUMMARY
Bereavement is an experience common to older adults. In many ways,
older adults experience bereavement differently from younger adults. These
differences are primarily in the intensity of the response to loss, the value of an-
ticipatory grief. and the relationship of bereavement to mortality and morbidity
effects. The age groups display similar psychological effects. Severe clinical de-
pression is a particular concern for the bereaved. Among the elderly, however,
the quality of negative appraisal frequently associated with clinical depression
is often absent, suggesting a possible diagnostic factor indicative of pathologi-
cal grieving instead of depression.
In this chapter, I addressed these differences and similarities by first, explor-
ing the characteristics of bereavement; second, examining the evidence for the ef-
fects of bereavement on the mental and physical health of the elderly bereaved;
third, presenting evidence for the benefits of social support in minimizing the
negative effects of bereavement; and fourth, describing treatment strategies for the
elderly who have difficulty in managing the pain of bereavement.
REFERENCES
Aldrich. C. (1974). Some dynamics of anticipatory grief. In B. Schoenberg. A. Carr. A. Kutscher. D.
Peretz. & 1. Goldberg (Eds.). Anticipatory grief (pp. 3-9). New York: Columbia University Press.
Arling. G. (1976a). The elderly widow and her family. neighbors. and friends. Journal of Marriage
and the Family, 38, 757-768.
Arling, G. (1976b). Resistance to isolation among elderly widows. International Journal of Aging
and Human Development, 7,67-86.
Averill. J. (1979). The functions of grief. In C. Izard (Ed.), Emotions ill personality and psy-
chopathology (pp. 339-368). New York: Plenum.
Averill, J., & Wisocki. P. (1981). Some observations on behavioral approaches to the treatment of
grief among the elderly. In H. Sobel (Ed.), Behavior therapy in terminal care (pp. 125-150).
Cambridge. MA: Ballinger.
Avis. N., Brambilla. D., Vass. K.. & McKinlay. J. (1991). The effect of widowhood on health: A
prospective analysis from the Massachusetts Women's Health Study. Social Science and Med-
icine, 33, 1063-1070.
Ball, J. (1976-1977). Widow's grief: The impact of age and mode of death. Omega. 7.307-333.
Bettis. S.• & Scott. F. (1981). BereaV'ement and grief. In C. Eisdorfer (Ed.). Annual review of geron-
tology and geriatrics (pp. 144-159). New York: Springer.
Bornstein. P., Clayton. P.• Halikas. J•• Maurice. W.• & Robbins. E. (1973). The depression of widow-
hood after thirteen months. British Journal of Psychiatry. 122. 561-566.
Bowlby, J. (1980). Attachment and 10ss:Vol. 3. Loss: Sadness and depression. New York: Basic
Books.
Bowling, A. (1988-1989). Who dies after widow(er)hood? A discriminant analysis. Omega: Journal
of Death and Dying. 19. 135-153.
Bugen.1. (1977). Human grief: A model for prediction and intervention. American Journal ofOr-
thopsychiatry. 47, 196-206.
Burnside. I. (1969). Grief work in the aged patient. Nursing Forum. 8.416-427.
Canton. M. (1983). Strain among caregivers: A study of experience in the United States. Gerontolo-
gist, 23. 597-604.
Carey. R. (1977). The widowed: A year later. Journal of Counseling Psychology. 24, 125-131.
Chambers. W.• & Reiser. M. (1953). Emotional stress in the precipitation of congestive heart failure.
Psychosomatic Medicine. 15. 38-60.
Clayton, P. (1979). The sequelae and nonsequelae of conjugal bereavement. American Journal of
Psychiatry, 136. 1530-1534.
Clayton. P., Halikas, J.. & Maurice. W. (1972). The depression of widowhood. British Journal of Psy-
chiatry. 1200. 71-78.
Clayton. P.• Herjanic. M.• Murphy. G., & Woodruff, R. (1974). Mourning and depression: Their sim-
ilarities and differences. Canadian Psychiatric Association Journal. 19, 309-312.
Dimond. M., Lund. D., & Caserta. M. (1987). The role of social support in the first two years of be-
reavement in an elderly sample. Gerontologist. 27. 599-604.
Dohrenwend. B. S., & Dohrenwend, B. P. (Eds.). (1974). Stressful life events: Their nature and ef-
fects. New York: Wiley.
Engel. G. (1961). Is grief a disease? Psychosomatic Medicine. 23. 18-23.
Farberow. N.• Gallagher, D.• Gilewski. M., & Thompson. L. (1987). An examination of the early im-
pact of bereavement on psychological distress in survivors of suicide. Gerontologist, 27,
592-598.
Ferraro. K. (1984). Widowhood and social partiCipation in later life: Isolation or compensation? Re-
search on Aging, 6,451-468.
Ferraro. K. (1985). The effect of widowhood on the health status of older persons. International
Journal of Aging and Human Development, 21, 9-25.
Freud. S. (1959). Mourning and melancholia. In J. Riviere (Thans.), Collected papers (Vol. 4, pp.
152-170). New York: Basic Books. (Original work published 1917)
Gerber, I., Rusalem. R.. Hannon. N.. Battin, D.• & Arkin. A. (1975). Anticipatory grief and aged wid-
ows and widowers. Journal of Gerontology. 30, 225-229.
Gerber. I., Wiener. A.• Battin. D.• & Arkin. A. (1975). Brief therapy to the aged bereaved. In
B. Schoenberg. I. Gerber, A. Wiener, A. Kutscher, D. Peretz. & A. Carr (Eds.), Bereavement: Its
psychosocial aspects (pp. 310-333). New York: Columbia University Press.
Glick. I., Weiss. R., & Parkes. C. (1974). The first year of bereavement. New York: Wiley.
Goldberg. E.• Comstock. G., & Harlow, S. (1988J. Emotional problems and widowhood. Journal of
Gerontology: Social Sciences, 43, S206-208.
Gorer. G. (1965). Death, grief, and mourning. London: Crescent.
Harlow. S.• Goldberg. I.• & Comstock, G. (1991a). A longitudinal study of the prevalence of depres-
sive symptomatology in elderly widowed and married women. Archives of General Psychia-
try. 48, 1065-1068.
Harlow. S.• Goldberg. I.• & Comstock. G. (1991b). A longitudinal study ofrisk factors for depressive
symptomatology in elderly widowed and married women. American Journal of Epidemiology,
134,526-538.
Helsing. K.. Comstock, G.• & Szklo, M. (1982). Causes of death in a widowed population. American
Journal of Epidemiology. 116, 524-532.
Heyman. D.• & Gianturco. D. (1973). Long-term adaptation by the elderly to bereavement. Journal of
Gerontology. 28. 359-362.
Hill, C. D., Thompson, 1., & Gallagher, D. (1988). The role of anticipatory bereavement in older
women's adjustment to widowhood. Gerontologist. 28, 792-796.
Jacobs, S., Melson, J., & Zisook, S. (1987). Treating depresssion of bereavement with antidepres-
sants: A pilot study. Psychiatric Clinics of North America. 10,501-510.
Kleber, R., & Brom, D. (1985). Psychotherapy and pathological grief controlled outcome study. Israel
Journal of Psychiatry and Related Sciences, 24, 99-109.
Kraus, A., & Lilienfeld, A. (1959). Some epidemiological aspects ofthe high mortality rate in the
young widowed group. Journal of Chronic Disease, 10, 207-217.
Kubler-Ross, K (1970). On death and dying. London: Tavistock.
LaRue, A., Dessonville, D., & Jarvik, L. (1985). Aging and mental disorders. In J. Birren & K. W.
Schaie (Eds.), Handbook of the psychology of aging (pp. 664-702). New York: Van Nos-
trand.
Lieberman, S. (1978). Nineteen cases of morbid grief. British Journal of Psychiatry, 132, 156-163.
Lindemann, K (1944). The symptomatology and management of acute grief. American Journal of
Psychiatry, 101,141-148.
Lopata, H. (1979). Women as widows: Support systems. New York: Elsevier.
Lundin, T. (1984). Morbidity following sudden and unexpected bereavement. British Journal of Psy-
chiatry, 144,84-88.
Maddison, D. (1968). The relevance of conjugal bereavement to preventive psychiatry. British Jour-
nal of Medical Psychology, 41. 223-233.
Maddison, D., & Viola, A. (1968). The health of widows in the year following bereavement. Journal
of Psychosomatic Research, 12, 297-306.
Mawson, D., Marks, I., Ramm, K, & Stern, R (1981). Guided mourning for morbid grief: A con-
trolled study. British Journal of Psychiatry, 138, 185-193.
McHorney, C., & Mor, V. (1988). Predictors of bereavement depression and its health services con-
sequences. Medical Care. 26, 882-893.
Melges, F., & Demaso, D. (1980). Griefresolution therapy: Reliving, revising, and revisiting. Ameri-
can Journal of Psychotherapy, 34, 51-61.
Mendes DeLeon, C., Kasl, S., & Jacobs, S. (1993). Widowhood and mortality risk in a community
sample of the elderly: A prospective study. Journal of Clinical Epidemiology, 46, 519-527.
Mendes DeLeon, C., Kasl, S., & Jacobs. S. (1994). A prospective study of widowhood and changes in
symptoms of depression in a community sample of the elderly. Psychological Medicine. 24.
613-624.
Morse. C.. & Wisocki, P. (1991). Residential factors in behavioral programming for elderly. In
P. Wisocki (Ed.), Handbook of clinical behavior therapy with the elderly client (pp. 97-120).
New York: Plenum.
Murrell, S.. & Himmelfarb. S. (1989). Effects of attachment bereavement and pre-event condition on
subsequent depressive symptoms in older adults. Psychology of Aging. 4. 166-172.
Murrell. S., Himmelfarb. S .• & Phifer, J. (1988). Effects of bereave mentl loss and pre-event status on
subsequent physical health in older adults. International Journal of Aging and Human Devel-
opment. 27, 89-107.
Mutran. K, & Reitzes. D. (1984). Intergenerational support activities and well-being among the el-
derly: A convergence of exchange and symbolic interaction perspectives. American SOciolog-
ical Review, 49, 117-130.
Norris. F.. & Murrell, S. (1990). Social support, life events. and stress as modifiers of adjustment to
bereavement of older adults. Psychology and Aging. 4, 150-165.
Norris, F.. & Stanley. S. (1987). Older adult family stress and adaptation before and after bereave-
ment. Journal of Gerontology, 42. 606-612.
Osterweis. M .. Solomon. F., & Green, M. (Eds.). (1984). Bereavement reactions. consequences. and
care. Washington, DC: National Academy Press.
Parkes. C. (1964). The effects of bereavement on physical and mental health: A study ofthe case
records of widows. British MedicalJournal. 2, 274-279.
Parkes. C. (1972). Bereavement: Studies of grief in adult life. London: Tavistock.
Pasternak, R, Reynolds, C.• Miller, M., Frank. E., Fasiczka, A.. Prigerson. H .. Mazumdar. S., &
Kupfer, D. (1994). The symptom profile and two-year course of subsyndromal depression in
spousally bereaved elders. American Journal of Geriatric Psychiatry, 2. 210-219.
Poulshock, S., & Deimling, G. (1984). Families caring for elders in residence: Issues in the mea-
surement of burden. Journal of Gerontology, 39, 230-239.
Rahe, R. (1979). Life change events and mental illness: An overview. Journal of Human Stress, 5, 2-10.
Ramsay, R. (1977). Behavioural approaches to bereavement. Behaviour Research and Therapy, 15,
131-135.
Rees, W. (1971). The hallucination of widowhood. British Medical Journal, 4, 37-41.
Richards, J., & McCallum, J. (1979). Bereavement in the elderly. New Zealand Medical Journal, 89,
201-204.
Roberto, K., & Scott, J. (1986). Confronting widowhood. American Behavioral Scientist, 29,
497-511.
Sanders, C. (1981). Comparison of younger and older spouses in bereavement outcome. Omega, 11.
217-232.
Schwarzer, C. (1992). Bereavement. received social support, and anxiety in the elderly: A longitu-
dinal analysis. Anxiety Research, 4, 287-298.
Siegel, J.• & Kuykendall, D. (1990). Loss. widowhood. and psychological distress among the elderly.
Journal of Counseling and Clinical Psychology, 58, 519-524.
Sireling, L., Cohen, D., & Marks, I. (1988). Guided mourning for morbid grief: A controlled replica-
tion. Behavior Therapy. 19, 121-132.
Skelskie. B. (1975). An exploratory study of grief in old age. Smith College Studies in Social Work,
45, 159-182.
Stern, K., Williams, G.• & Prados, M. (1951). Griefreactions in later life. American Journal of Psy-
chiatry. 108,289-293.
Stroebe, W.• & Stroebe. M. (1987). Bereavement and health. Cambridge. England: Cambridge Uni-
versity Press.
Thompson. L.• Breckenridge, J.• Gallagher. D.. & Peterson. J. (1984). Effects of bereavement on self-
perceptions of physical health in elderly widows and widowers. Journal of Gerontology, 39,
309-314.
Vachon. M., Freedman, K., Formo, A., Rogers, J., Lyall, W., & Freeman, S. (1977). The final illness in
cancer: The widow's perspective. Canadian Medical Association Journal, 177,1151-1154.
Volkan, V. (1975). "Re-grier' therapy. In B. Schoenberg, I. Gerber, A. Wiener, A. Kutscher, D. Peretz,
& A. Carr (Eds.), Bereavement: Its psychosocial aspects (pp. 334-350). New York: Columbia
University Press.
Wahl, C. (1970). The differential diagnosis of normal and neurotic grieffollowing bereavement. Psy-
chosomatics, 11, 104-106.
Walker, K., MacBride, A., & Vachon. M. (1977). Social support networks and the crises of bereave-
ment. Social Science and Medicine. 11,35-41.
Wiener, A., Gerber, I., Battine, D., & Arkin, A. (1975). The process and phenomenology of bereave-
ment. In B. Schoenberg, I. Berger, A. Wiener. A. Kutchner. D. Peretz, & A. Carr (Eds.). Be-
reavement: Its psychsocial aspects (pp. 53-65). New York: Columbia University Press.
Wisocki, P., & Averill. J. (1988). The challenge of bereavement. In L. Carstensen & B. Edelstein
(Eds.). Handbook of clinical gerontology (pp. 312-321). New York: Pergamon.
Wolinski, F., & Johnson, R. (1992). Widowhood, health status. and the use of health services by
older adults: A cross-sectional and prospective approach. Journal of Gerontology: Social Sci-
ences, 47, 8-16.
Worden, J. (1982). Grief counseling and grief therapy: A handbook for the mental health practi-
tioner. New York: Springer.
Wortman. C.• & Silver. R. (1987). Coping with irrevocable loss. In G. VandenBos & B. Bryant (Eds.).
Cataclysms. crises, and catastrophies: Psychology in action (pp. 185-235). Washington, DC:
American Psychological Association.
CHAPTER 20
Marriage and Divorce

GARY R. BIRCHLER AND WILLIAM FALS-STEWART
INTRODUCTION
By the year 2000, 13% of the U.S. population will be over 65 years old (Peter-
son and Bahr, 1989); by 2040 it is estimated that this proportion will reach
nearly 25% (Goldberg, 1992). Soon the average American will live up to 25
years after raising children to adulthood. A quarter of one's adult life may be
spent in retirement. People entering retirement may have to deal with taking
care of their aging parents as the number of people over 75 years of age in-
creases (Goldberg, 1992). These significant changes in the demographics of our
aging population suggest that families will be composed of more older people
and fewer younger people; more divorces and remarriages will require impor-
tant adjustments between husbands and wives. In particular, there is concern
for women in their late 50s and 60s who will be called upon to care for (a) their
elderly parents, (b) their adult children, and (c) their spouses (Goldberg, 1992;
Peterson and Bahr, 1989). Because women generally outlive their husbands by
a decade, it begs the question, "Who will provide for these women?" In this
ominous context, marriage, as the persistent and venerable institution that it is,
will become more challenged and will be an important resource for the elderly.
On a more positive note, many elderly couples are expected to become more
active, more secure financially because they have two incomes, and more healthy
and long-lived as a consequence of advances in medical technology. Nevertheless,
economic and social support for older adults could become threatened (Neidhardt
& Allen, 1993). The need for home health care is expected to grow tremendously
(Goldberg, 1992; Peterson & Bahr, 1989). Consequently, there will be increasing
pressure on the family to care for older family members, coming at a time when
increasing numbers of the elderly from all racial and ethnic groups are living
alone by choice or because oflack of alternatives (Lee, 1986; Mindel, 1986).
GARY R. BIRCHLER • Department of Psychiatry. School of Medicine. University of California, San

Diego. La Jolla. California 92093-0603. WILLIAM FALS-STEWART • Department of Psychology. Old
Dominion University. Norfolk. Virginia 23529-0267.
449
450 Gary R. Birchler and William Fals-Stewart
RECOGNIZED BIASES
Much of the literature in the area of marriage and the elderly has focused
on retirement (cf. Szinovasz, Ekerdt, & Vinick, 1992). Relatively little attention
has been devoted to a family systems conceptualization of the aging process.
Apart from investigations of gender role transitions as a result of retirement,
family life cycle theories and research have generally neglected older persons
during the postparental and culmination stages of the marital life cycle (Birch-
ler, 1992; Carter and McGoldrick, 1988). This book is an example of the recent
attempts to consolidate and promote the field of geropsychology. We must real-
ize the developmental potential of all generations in the family. To this end,
Flori (quoted in Goldberg, 1992) recommends that mental health care providers
take a position of therapeutic realism, as opposed to therapeutic pessimism or
therapeutic idealism. Exam.ples of therapeutic pessimism include (a) notions
that because elderly couples have a limited capacity to change their beliefs, in-
terventions are better devoted to the younger generations, (b) the idea that vali-
dating and confirming long-standing patterns of behavior and beliefs is better
than expecting changes in them, and (c) beliefs that in treating elderly clients
one cannot have much hope for the future; it is preferable to work for accep-
tance of the inevitable. Such views are not in the best interest of older persons.
However, at the other extreme, therapeutic idealism also can miss the mark;
practitioners with this bias often minimize age-specific concerns and develop-
mental changes that must be recognized in order to best meet the needs of el-
derly couples. Seeking a balance between these viewpoints, therapeutic realism
accounts for the personal strengths and vulnerabilities of the elderly couple.
When understood, validated, and encouraged, the elderly couple has signifi-
cant potential to become as vibrant, efficient, and competent as their younger
counterparts (Wolinsky, 1990).
In this chapter, we will discuss the strengths and vulnerabilities of older
couples and review briefly certain better-known aspects of marriage during the
postparental and culmination stages of the marital life cycle. The status and im-
plications of divorce and remarriage among the elderly also will be explored.
Finally, an approach to working with older adults in the context of conjoint
marital therapy will be described.
THE MARITAL RELATIONSHIP

OF OLDER COUPLES
The marital relationships of older couples can best be described by posing

and answering a number of relevant questions. Answers to these questions de-
lineate the requisites for viable long-term relationships, illustrate the strengths
of older marriages, and highlight vulnerabilities to be identified and treated in
therapy. It should be noted that most of the research and the following discus-
sion pertain, in general, either to first marriages or to long-term second or third
marriages. The developmental tasks and evolution of relationship dynamics ap-
ply most appropriately to two people living together and experiencing an "older
marriage," not just older people who become married or remarried. Character-
istics of remarriages will be discussed later in this chapter.
Marriage and Divorce 451
1. How are older marriages different from younger marriages?
This information is organized according to lifelong changes in marital satis-

faction and four important core dimensions or requisites of a longterm intimate
relationship: The 4 Cs (Le., Commitment, Caring, Communication, and Conflict
resolution: Birchler & Fals-Stewart, 1994a; Birchler & Schwartz, 1994; Nichols,
1988). As for changes in marital satisfaction over the marital life cycle, reason-
able consensus exists that marital satisfaction follows a curvilinear pattern
(Miller, 1976; Rollins & Cannon, 1974; Spanier, Lewis, & Cole, 1975; Troll, 1986).
In order of development, the five stages of the traditional marital life cycle have
been described by Birchler (1992): Newlyweds, Parents Or Not To Be, Mid-life
Adolescence (of the adults), Postparental, and Culmination. Newlyweds are the
happiest, followed by postparental couples (Le., couples early in retirement).
Couples in the parenting stage or marriages in the midlife adolescence of their
relationship generally are the least satisfied and most conflicted. In particular,
child-rearing and occupational issues seem to trouble many marriages (J. M.
Lewis, 1988; J. M. Lewis, Owen, & Cox, 1988; Nadelson, Polonsky, & Mathews,
1984). Couples experiencing the culmination stage of marital life are nearly as
satisfied as the somewhat younger postparental couples, particularly if they can
retain their health and financial security (Gilford, 1984; Lee, 1988).
Commitment between elder spouses seems to evolve from the passion, in-
dependence, and volatility experienced in youth, eventually to attaining a level
of profound loyalty, mutual sharing of activities, a sense of fairness, and a com-
fortable interdependency in meeting the day-to-day practical challenges of life
(Traupmann & Harfield, 1983; Troll, 1986). Caring, including support and un-
derstanding, cohesion, affection, and sexual interaction, evolves from physical
attraction and higher intensity emotionality to more stable elements of attach-
ment, mutual caregiving, and, for some, continuing sexual activity emphasizing
warmth and closeness. Sexual activity and marital satisfaction correlate posi-
tively (Hammond, 1989), but for many older couples sex is not essential (Troll,
1986). Over time, Communication also reaches a more mature form of develop-
ment. Older couples have a long-term perspective; they are inclined to experi-
ence humor, playfulness, and possess good communication skills (Lauer, Lauer,
& Kerr, 1990). Finally, Conflict resolution patterns often change from the uneven,
high-conflict, demand-withdraw, or disengaged styles characteristic of younger
marriages to a more passive, consensus-based pattern of low conflict. Even older
distressed marriages tend to have many fewer domestic disagreements (Birchler
& Schafer, 1990; Condie, 1990; Fals-Stewart, Schafer, & Birchler, 1993; Levenson,
Carstensen, & Gottman, 1993, 1994). Cuber and Haroff (1965) found that older
couples were more likely to fit their passive-congenial and devitalized types of
marriage (compared to the total, vital, or conflict-habituated types).
2. Is marriage good for older people? Are there gender differences

in the quality experienced?
A sizable body of research supports the physical and emotional value of be-
ing married over being widowed or divorced for both men and women (Gold-
berg, 1992; Quiroutte & Gold, 1992). Married older people live longer, experience
higher life satisfaction, smoke less, are less depressed, have more financial re-
sources, and have lower rates of institutionalization. However, beyond the state
of marriage, and especially for women, it is the quality of the marriage that ap-
pears to be even more important for individuals' physical and emotional well-
being. More specifically, the positive association between the state of being
married and mental health is stronger for men, whereas marital satisfaction is a
stronger predictor for women's mental health than it is for men's mental health.
In particular, Quirouette and Gold (1992) found that the three variables that best
predicted wives' psychological well-being were (a) husbands' perceptions of the
marriage, (b) husbands' positive well-being, and (c) husbands' physical health.
The authors interpreted these findings from a traditional perspective, suggesting
that because caring for children and the family has been the wives' responsibil-
ity, their husbands' satisfaction serves as a powerful determinant of their own
self-esteem. That is, their husbands' perceptions of the quality of the marriage re-
flect on the wives' levels of competency and thus affect their psychological well-
being. Moreover, with advancing age men tend to become more dependent on
their wives for nurturance, social interaction, and assistance with disabilities,
thus reinforcing wives' caregiver roles. Therefore, when the husbands' senses of
well-being are positive, so are their wives'.
3. What are the basic requisites and developmental tasks

associated with a long-term intimate relationship?
It is estimated that only 20% of first marriages will survive to their golden
anniversaries (Brubaker, 1983; Glick & Norton, 1977). What does it take to reach
this amazing milestone? Wynne (1984), suggests that long-term intimate rela-
tionships require a mutual commitment to the marriage, attachment and affec-
tional bonding, communication and problem-solving skills (note that these
dimensions are similar to the 4 Cs discussed previously). Cole (1986) has pro-
posed seven developmental tasks or achievements of high-quality long-term
marriages (Cole, 1989) which help partners in older marriages avoid loneliness,
reduce conflict and feel understood: (1) Establish an effective communication
system, (2) be aware of one's own and other's thoughts, feelings, and actions so
one can be responsive to partner's needs, (3) build and maintain a high level of
self-esteem, (4) become comfortable with ambivalence, (5) develop awareness
of one's own and one's partner's sexual needs and desires, (6) be comfortable
with partner's differences and use conflict resolution tools in a creative way,
and (7) develop problem-solving skills to reach mutually agreeable solutions.
Once again, the general emphasis of Cole's analysis is on the 4 Cs.
As energy levels and health change, it is also important for partners in
older couples to (a) establish predictable daily patterns and routines to manage
activities of daily living, such as housing, finances, and social activities, (b)
simplify their lifestyle (Le., retain fewer material possessions and reduce the
number of routines and responsibilities), (c) develop and maintain healthy
habits regarding sleeping, eating, vitamins, and exercise, (d) shift and balance
workloads based less on traditional gender role responsibilities and more on
ability and cooperation, and (e) develop a plan for long-term financial security.
The final years together are significantly more rewarding if couples develop an
effective retirement plan, learn to cope with health limitations and reduced en-
ergy levels, and successfully face their own mortality through advance planning
(Askham, 1994; Swenson, Eskew, & Kohlhepp, 1981). Finally, family and social
relationships can be critical during the culmination stage of the marital life cy-
cle. Not only do spouses need to realize and correct for imbalances in amount
of separateness and togetherness, but each partner must make similar adjust-
ments with respect to their children, grandchildren, siblings, and same-genera-
tion family and friends.
4. What causes problems for older people in older marriages?

What are the areas of vulnerability?
Consensus among gerontologists is that the two greatest threats to older
couples are health problems and financial insecurity or poverty (Askham, 1994;
Atchley, 1992; Condie, 1989; Hess & Markson, 1986; Quirouette & Gold, 1992).
Unfortunately, disability and poverty tend to interact and together they are a
significant threat to society as the U.S. population ages. Spousal mental or
physical illness has a detrimental effect on both partners' psychological well-
being. Major illness also negatively affects marital satisfaction, especially if the
couple was experiencing marital distress before the onset of health problems
(Quirouette & Gold, 1992). Typically, because wives are more frequently cast in
the role of the caregiver, they suffer more or less depending on the level of mar-
ital quality. Although high-quality marriages seem to cope fairly well with
physical illness, psychiatric illness in the husband significantly affects the psy-
chological well-being of the wife, despite the premorbid level of marital satis-
faction. Less is known about how husbands cope with their wives' health
problems, but the level of marital satisfaction, for men, seems to be a less sig-
nificant factor in their mental health.
Financial insecurity and poverty potentially have grave implications for
the elderly. Virtually all aspects of their lives can be adversely affected if finan-
cial resources are insufficient. The resources include living arrangements (e.g.,
location and quality of housing, dependence on children or other relatives,
space and privacy, need to move), health maintenance (e.g., access to health
care. preventive versus remedial care, nutritional aides, illness and institution-
alization), and general quality of life options (e.g., travel, material needs and
desires, social activities and telecommunications). To the extent that the gov-
ernment reduces economic support in these areas, families will be challenged
to compensate-and these changes will affect everyone in our society.
Apart from health and financial difficulties, older couples also are increas-
ingly vulnerable to marital and life dissatisfaction if they have not succeeded in
coping with or mastering the developmental tasks just described. Distressed
older couples are susceptible to power struggles, high conflict, and isolating
avoidance patterns if they have not developed collaborative mutuality in the 4
Cs: Commitment, Caring, Communication, and Conflict resolution. The failure of
the partners in the relationship to develop adaptive interactional processes for
managing stressful events (Karney & Bradbury, 1995) may lead to a low-quality
passive-congenial type of existence at best, or to a lonely and devitalized rela-

tionship (Cuber & Haroff, 1965), or it may culminate in separation and divorce
(R. A. Lewis & Spanier, 1979).
For ethnic and cultural minorities (e.g., Hispanic and African American
families), some recent trends are disturbing. A smaller percentage of members
from these groups is getting married, separation and divorce rates are increasing,
widowhood is occurring at an alarmingly earlier age, economics are worsening,
and traditional familialism and extended family caregiving among these groups
are deteriorating. Taken together, it appears that marital satisfaction among el-
derly cultural minority groups is likely to be lower in the future (Troll, 1986).
Research on other effects of major life events on marital satisfaction have
produced mixed findings, with a variety of modifying variables found across
studies. For example, departure of children from the home sends many couples
into marital distress; yet, in many other cases, this event is liberating and in-
vigorating to the couple (Troll, 1986). Similarly, retirement (discussed next)
causes significant problems for some couples, but most adapt gradually and
successfully, often with little apparent effect on marital quality (ef. Troll, 1986).
5. What are the effects of retirement on marriage?
As mentioned previously, this is the most researched area and the best-doc-
umented aspect of older marriages (Atchley, 1992; Dorfman. 1992; Vinick & Ek-
erdt, 1992). Accordingly, only the persistent findings are summarized here.
First of all, the marital relationship is a central aspect of postparentallife; esti-
mates are that 87% of men and 65% of women who retire are married (Atchley,
1992). However, some preretirement expectations do not completely match
postretirement experiences. Although men expect and experience more change
in retirement than do their wives, husbands tend to overestimate the amount
of time they will have for leisure activities (Vinick & Ekerdt, 1992). Wives par-
ticipate in household activities to a similar extent before and after retirement,
but they underestimate how much husbands will actually "help" them. Hus-
bands also have more time for masculine-type household activities (e.g., yard-
work. mechanics, woodworking). Interestingly, in one major study (Vinick &
Ekerdt,1992), half of the retired couples experienced little or no change in their
activities from pre- to postretirement. If planned for adequately, retirement has
been found to have relatively little effect on marital satisfaction, especially
compared with adverse life events such as declining health, disability, loss of
employment, or reduced income.
Retired couples do indicate that they have more time for mutually rewarding
activities together, increased communication, and , if required, mutual caregiving.
In retirement, marital satisfaction for men tends to increase because there is less
competition for their time and interest from nonmarital roles (Lee, 1988). How-
ever, a similar effect was not found for wives. Today, if not in the future, most cou-
ples approach voluntary retirement with adequate income, a stable relationship,
high self-esteem, and good coping skills (Atchley, 1992; Dorfman, 1992).
For some unfortunate older couples, retirement may cause or exacerbate
certain problems. Partners' sex-role routines and personal privacy and space
may be disrupted. There can be unrealistically high expectations of what will

be garnered from the marriage after retirement (e.g., to compensate for years of
miscommunication and inattention to the relationship). Increased time together
also can cause a conflict over roles; power struggles over dominance in the
household can result. Couples who have failed to master the 4 Cs and the other
requisite developmental tasks described previously can encounter serious dif-
ficulties and disappointments if retirement puts pressure on the marital rela-
tionship to provide most of life's satisfactions.
In summary, although partners in elderly couples may become quite in-
terdependent and may even have fewer friends and activities outside of mar-
riage than do their widowed or divorced counterparts, most older couples do
adjust rather well to retirement and marital satisfaction is relatively high.
However, some couples enter old age continuing a long-standing pattern of
marital dissatisfaction, others encounter difficulties as a result of retirement,
and still others do well until the relationship is impacted by a significantly ad-
verse life event. In the latter cases, dissolution of the relationship is becoming
more frequently employed as a solution to perceived relationship problems
among the elderly.
DIVORCE AMONG THE ELDERLY
Surprisingly few studies have explored the relationship between aging and
divorce. What little literature exists typically has focused on the impact of di-
vorce on women, primarily because they are at the greatest risk for economic,
social, and emotional adjustments after divorce (Hennon, 1983; Morgan, 1992;
Uhlenberg, Cooney, & Boyd, 1990). Once again, consider that, overall, the di-
vorce rate for first marriages is about 66% (Castro-Martin & Bumpass, 1989).
The remarriage rate is 75% within five years of divorce, and yet 44% of these
relationships also end in divorce (Hennon, 1983).
Although rate of divorce decreases as the population ages, divorce after age
40 is not uncommon. For example, in 1985,23% of divorced women were over
age 40, 2% were over age 60 and 1.3% were over age 65 (representing about
10,000 divorces among older persons each year) (Hennon, 1983). Despite the
comparatively low divorce rate among elderly couples, there is a concern that
divorce rates for older adults are increasing. Divorce has become a more viable
and acceptable solution to marital problems throughout our society. From 11 %
to 18% of women in first marriages after age 40 will obtain a divorce. Of all mar-
riages that survive 15 years, 17% will end in divorce; 11 % that last at least 20
years will end in divorce. Divorce feeds on itself. We now expect more from
spouses; people are less reluctant and more able financially to engage in serial
monogamy. Attesting to this pattern is the high remarriage rate; in the case of
the elderly, this is especially true for men. For women, remarriage rates decline
sharply with age and are quite low after age 45 (3% remarry in the first year af-
ter divorce compared to a 30% remarriage rate for women under 25).
Conservative projections are that less than half of the women born between
1955 and 1959 will be in first marriages at midlife (Uhlenberg et a1., 1990). One
third of these women will be living outside marriage either in single, divorced,
or widowed status. For older women, implications of these increasing divorce

and declining remarriage rates are not promising. Research indicates that rela-
tive to married, single, or widowed women, divorced females (a) have fewer fi-
nancial resources, (b) have to work longer than their counterparts, (c) generally
suffer more from psychological and self-esteem problems, (d) experience more
distress and conflict associated with their families, and (e) experience more dis-
ruption in their social contacts and living arrangements (Hennon, 1983; Lee,
1986; Morgan, 1992; Peterson & Bahr, 1989; Uhlenberg et aI., 1990). Moreover,
consequences for long-term divorced women are almost as severe as for re-
cently divorced older women.
Today's high divorce and remarriage rates among the general population
will certainly affect and disrupt family relationships in the years to come.
More divorces will cause increased emotional trauma and greater socioeco-
nomic problems. The subsequent increases in second and third marriages
surely will complicate extended family relationships. Indeed, the divorce rate
among those over 65 years of age is ten times higher for remarriages than it is
for first marriages. We believe that following a divorce, men may suffer more
than women psychologically because relative to women, older men are more
dependent on marriage for intimacy and caregiving. Death rates for divorced
males over 65 are 35% higher than for married males; this differential is only
7% for women. However, as just indicated, women are significantly more at
risk financially and are more likely to encounter difficulties starting over
(Hennon, 1983). Increasing divorce rates, in general, also mean that more older
women are likely to have adult children who are divorced. This trend has sig-
nificant implications for availability of supportive resources for older women.
Divorced women in the middle generation are in need of support from their ag-
ing parents, who, in turn, are in need of support from their daughters. If the
majority of women are divorced and are members of reconstituted families,
sources of critical support are complicated and likely to be reduced for both
generations. We briefly present some specific information about remarriage
among older persons.
REMARRIAGE AMONG THE ELDERLY
Although in the U.S. more than 20% of all marriages are remarriages, rela-
tively little is known about this phenomenon among the elderly (Bowers &
Bahr, 1989). We do know that divorced older women (a) tend to be younger than
widowed older women, (b) are more likely to be living with children, (c) are
less likely to be obligated to a dead spouse, and (d) they are more likely to be in
need of economic support. Based on these factors, relative to widowed women,
divorced women are more likely to remarry. After age 60, 16% of divorced
women remarry. compared to 3% of widowed women (Bowers & Bahr, 1989). A
similar pattern is expected among men, but definitive research on this question
is not yet available.
Remarriage rates are much lower for women than men because of several
factors: (a) There is a sex ratio pool of only two men for every three women at
age 65, and this discrepancy increases with age, (b) widows are less inclined to
remarry than are widowers, who are more dependent on marriage, and (c) our
cultural values dictate that men are able to marry much younger women than
vice versa, further improving their selection advantage (Bowers & Bahr, 1989).
The purpose of remarriage seems to be different for older compared to
younger couples. Elderly couples are interested primarily in companionship
and someone to help in the practical navigation of later life. Accordingly, re-
marriages among older couples appear to be much more stable than are younger
remarriages (53% of women in remarriages before age 50 get divorced com-
pared to only 22% after age 50). The older the age at remarriage, the more stable
the relationship seems to be. Interestingly, there appear to be no significant dif-
ferences in marital satisfaction between younger and older remarried couples.
However, some studies suggest that older men are more satisfied with their re-
marriages than are older women. Again, this finding may be a function of the
greater need that men appear to have for marriage and their greater pool of po-
tential partners (Bowers & Bahr, 1989).
MARITAL THERAPY FOR OLDER COUPLES
In comparison with their younger counterparts, the current cohort of el-

derly couples is more reluctant to request mental health services. If marital dif-
ficulties are encountered, they initially tend to seek guidance from their
primary care physician or a member of the clergy. Those referred to a marital
therapist, often by their adult children, present clinical problems and need ther-
apeutic interventions that are similar to problems and interventions for younger
couples (Gatz, Popin, Pino, & VandenBos, 1985). However, there are diagnostic
and assessment issues as well as specific methods of facilitating engagement in
the therapeutic process that should be considered when treating elderly cou-
ples. Let us discuss these three points in more detail.
Presenting Problems
Lauer, Lauer, and Kerr (1990) have described four types of marriage among
older persons: (a) long-term maritally satisfied, (b) long-term dissatisfied, (c)
short-term pleasurable, and (d) short-term distressed. Satisfied couples do not
seek marital therapy; dissatisfied groups are referred for marital treatment. Of
the two dissatisfied groups, the short-term dissatisfied are the most likely to
seek treatment. They may represent either long-term marriages disrupted by
sudden changes or losses that overwhelm one or both spouse's ability to cope,
or they may be remarried couples who find themselves in conflict due to any
number of adjustment problems or apparent incompatibilities. In any case,
these couples tend to be good candidates for marital therapy.
When older couples enter marital therapy, the basic content areas about
which they are concerned are similar to the issues presented by younger cou-
ples: financial stressors, disputes regarding (adult) children (or grandchildren),
conflicts about personality styles and behavioral habits, and perhaps problems
regarding sex and affection (Birchler & Fals-Stewart, 1996; Rosenberg, 1989;
Stone, 1987). However, these issues that are found in common with younger
couples are very likely to be salient for second or third marriages, where sex,
money, relationships with adult children, and rigid personal styles often re-
quire mutual adjustment. In remarriages the strong desire for companionship
does not obviate the need for accommodation to each partner's families and to
each partner's long-standing beliefs, values, and behavior patterns.
In contrast to remarried older couples, partners in long-term marriages usu-
ally have resolved many of the marital problems typical of younger couples
(Birchler & Schafer, 1990; Fals-Stewart et aI, 1993; Rosenberg, 1989). No longer
are money management, career conflicts, frequency and variety of sex activities,
and disciplining the children the most prominent issues. More likely, a healthy
spouse is appearing on behalf of an unhealthy partner; spouses are seeking as-
sistance in adjusting to any of a number of losses in their lives. Careful assess-
ment of these losses and partners' attempts and successes at coping with them
are important from both assessment and intervention perspectives. These po-
tential and some inevitable losses include residence; family and friends; finan-
cial security; children moving out of the home or away from town; changes in
personality, mental status, or physical capabilities; reduced energy or sensory
impairments; and diminished self-esteem associated with loss of youth, voca-
tional activities, or role and life expectations (Gafner, 1987; Stone, 1987). Con-
sequently, much of the therapeutic work that can be done is based on a
compensatory model of aging, namely, assisting couples to accept the aspects of
their losses that cannot be changed, helping them restore aspects lost but re-
storable, and helping partners to substitute or compensate for losses to the ex-
tent possible (Stone, 1987).
Basic Interventions
Most of the basic types of interventions that therapists might use to assist
elderly couples with marital problems vary little from contemporary ap-
proaches employed with all distressed couples (Birchler & Fals-Stewart, 1996;
Gafner, 1987, Stone, 1987). Indeed, we have found cognitive and behavioral ap-
proaches to be quite compatible with the treatment needs of older couples. Fre-
quently, treatment goals are expressed in concrete and behavioral terms. Most
elderly couples are neither candidates for, nor do they plan on altering their
long-standing belief systems. More likely, they simply desire to bring their per-
sonal and relationship function in accordance with their long-standing beliefs.
In addition, most older couples do not seek insight-oriented or emotionally fo-
cused therapy. Despite their proclivity and apparent need to tell stories about
their life experiences (Butler, 1974), partners in the couples want to learn ex-
peditiously how to compensate for what they have lost or to reconcile conflicts
associated with external stressors or recent remarriages. Accordingly, these cou-
ples often prefer a relatively brief, directive, communication and problem-solv-
ing oriented therapeutic approach (Stone, 1987). In addition, in a directive role,
the therapist may need to be an active mediator and provide more explicit ad-
vice than is typically required for younger couples.
The 7 Cs Model
By incorporating the diagnostic and therapy-engagement procedures de-

scribed in the next section, we have quite successfully used the 7 Cs model to
assess and treat many elderly couples. The model will be only briefly outlined
here; the four core dimensions (the 4 Cs) were introduced earlier. The interested
reader is referred to Birchler and Fals-Stewart (1994a), and Birchler and
Schwartz (1994) for a more extensive discussion ofthe 7 Cs formulation for the
assessment and treatment of marital dysfunction.
In their entirety, the 7 Cs include: Character features, Contract, Cultural
and ethnic factors, Commitment, Caring, Communication, and Conflict resolu-
tion. Aspects of the 7 Cs are assessed using a series of behaviorally oriented in-
terviews (Birchler & Schwartz, 1994), a paper-and-pencil Marital Relationship
Assessment Battery (Birchler, 1983; Birchler & Fals-Stewart, 1996), and obser-
vation of a 10-min sample of marital conflict communication between partners
(Basco, Birchler, Kalal, Talbott, & Slater, 1991; Birchler, 1983).
Character features relate to obstructive personality features and the extent
of psychopathology present in one or both partners. The continuum of concern
ranges from rigid and dominating personality styles, to moderate levels of psy-
chiatric disturbance in one spouse (e.g., depression and anxiety), to presence of
major psychiatric disorders in both partners (e.g., both spouses have bipolar de-
pressive disorder; one experiences major depression and the other has a sub-
stance abuse problem). The more severe or complex the character features
presented by the couple the more likely that individualized treatments will be
required either before, concurrent with, or instead of marital therapy (Fals-
Stewart, Birchler, Schafer, & Lucente, 1994).
Contract refers to the discrepancy between what partners expect to gain
from the marriage and their actual experiences in the relationship. In the ab-
sence of good communication and problem-solving skills, unrealistic or diver-
gent partner expectations lead to unrealistic demands, which results in
resentments and highly frustrating marital conflict. Some older couples have
implicit contract problems (i.e., the nature ofthe conflict is outside their aware-
ness or beyond their present knowledge), others have explicit contract problems
and frank disagreements (e.g., the husband expects his wife to restrict her time
and activities with her adult children and their families and she married him
expecting to expand and enjoy access to these families). Most contract problems
for older couples in long-term marriages arise as a result of significant life-event
changes (e.g., retirement, disability, or other personal growth-related differences
between partners). Remarried partners more frequently perceive that they are
not getting what they expected from their new partner (e.g., sexual activity,
caregiving, help with household chores, financial income, access to or lack of
interference from adult children). Treatment includes helping couples identify,
clarify, and negotiate and reconcile these various implicit and explicit differ-
ences between partners' expectations and experiences.
Cultural and ethnic factors are contextual variables that may affect the mar-
ital relationship and the prospects for successful therapy. Family of origin is-
sues are included in this area because certain beliefs, experiences, and cultural
traditions from partners' original families may impact the marriage signifi-
cantly. Potential problems to be addressed i~clude conflict between the spouses
concerning racial, ethnic, religious, and socioeconomic class issues. In addi-
tion, some couples not only have such conflicts within the marriage, they are
struggling against outside interference from family, friends, or society in gen-
eral. Finally, it is also possible that the therapist comes from a significantly
different sociodemographic background (e.g., different race, religion, or sig-
nificantly younger group than the older couple). In the case of a significant age
difference, elderly clients may feel that very young therapists do not have suf-
ficient life experience to understand and be able to treat them; young therapists
may feel that they are being treated like the couples' adult children. If any of
these age, cultural, or ethnic factors threaten the prospects for successful ther-
apy, then case consultation, case management adjustments (e.g., adding a cul-
turally matched cotherapist to enhance ethnic or racial understanding), or
perhaps a referral to another therapist or setting may be required to achieve
compatibility. Older couples, especially in circumstances ofremarriage, are not
immune from the complicating and conflicting effects of cultural and ethnic
factors. Any such problems must be addressed and resolved before one can ex-
pect a positive outcome from conjoint therapy.
Commitment refers to three interrelated areas: commitment to the marriage
(stability), commitment to change (quality), and commitment to the therapeutic
process. Of course, it is optimal if both partners have strong personal commit-
ments at all three levels. Unfortunately, entering marital therapy, typically one
or both partners fall short in one or more of these three types of commitment.
When the assessment process reveals deficiencies in commitment, the underly-
ing issues must be addressed early in therapy. Partners in long-term marriages
more likely are committed to stability, but they may need encouragement to
commit to quality (Le., positive change) in the relationship and to the therapy
process itself. Older remarried couples frequently have commitment problems
in all three areas. Commitment evolves from reliable experience, trust, and ex-
pectations for positive relating. Therefore, whatever the therapist can do to join
with the clients, to demonstrate competence, to underline credibility for the ap-
proach, and to engender hope for future relating contributes to strengthening
partners' commitments.
Caring encompasses mutual support and understanding, attachment, cohe-
sion, demonstrations of affection, and sexual interaction. Once again, partners
in long-term marriages usually measure up well in this area unless they are
challenged by emotional or physical disabilities that have disrupted and dam-
aged the caring bond between partners. Conversely, remarriages are subject to a
number of challenges that typically do not confront long-term marriages. Be-
cause many older people remarry for companionship and practical interdepen-
dency, there may be conflicts regarding the various ways of demonstrating
caring. Therapeutic interventions include "Caring Days" (Stuart, 1980), "Love
Days" (Weiss & Birchler, 1975), development of both independent and mutually
rewarding activities (Birchler, 1983), other exercises to facilitate and enhance
the expression of affection Uacobson & Margolin, 1979), and, if appropriate, sex-
ual relationship enhancement interventions (Gottman, Notarius, Gonso, &
Markman, 1976; Heiman, 1986; Stone, 1987).
Communication is a critical skill for older and younger couples alike. Ex-
cept for the fortunate few golden anniversary couples, many elderly couples
who are referred for marital therapy have lost or have never had the opportunity
to be fully understood and personally validated. Older men often are inclined
to have some difficulty in expressing feelings, while their wives often have
more difficulty being assertive. Moreover, as discussed throughout this chapter,
these couples usually present under stress while attempting to cope with one or
more significant losses. If such losses are profound and emotionally disturbing,
even couples with adequate communication skills find themselves in distress
and need assistance in identifying, exploring, sharing, and resolving their prob-
lems. Remarried older couples frequently need extensive work in developing
better communication skills; fortunately, they are often willing and successful
participants. Communication skills training (Birchler, 1979; Gottman et 01.,
1976; Jacobson & Margolin, 1979; Notarius & Markman, 1993) provides a sup-
portive and instructive environment to help motivated couples speak as-
sertively and listen attentively to their mates (for a case study of an older
couple, refer to Birchler and Fals-Stewart, 1996).
Conflict resolution refers to three levels of interaction: (a) day-to-day deci-
sion making, (b) mutual problem solving of life's problems and relationship is-
sues, and (c) actual conflict management skills needed to resolve overt and
covert emotionally charged disputes. Older couples can have certain difficulties
at all three levels of conflict resolution. For the most part, long-term marriages
are characterized by conflict avoidance and passive responses to marital conflict
(Birchler & Fals-Stewart, 1994b). However, the usual caveat applies-if a partner
experiences a major mental or physical disability, his or her emotional equilib-
rium may be disrupted, resulting in an irritable disposition and sometimes cul-
minating in hostility and violence between otherwise compatible partners. As
mentioned previously, in such situations, careful medical, psychological, and
neuropsychological assessments are indicated to help determine the causes and
develop appropriate treatment plans. Alternatively, sometimes short-term re-
married partners present for marital therapy and benefit from the standard cog-
nitive-behavioral treatments developed for general problem solving and
designed for acute, interpersonal conflict management (Gottman, et aI., 1976; Ja-
cobson & Margolin, 1979; Notarius & Markman, 1993).
In summary, the 7 Cs model represents universal dimensions of marital re-
lationships, whether the participants are younger or older in age and regardless
of the length of the marriage. Combined with special assessments and engage-
ment-enhancement procedures enumerated in the following sections, interven-
tions based on the 7 Cs and an integrated behavioral couples therapy approach
(Christensen, Jacobson, & Babcock, 1995) serve well to help older couples ben-
efit from brief marital treatment experiences.
Special Considerations
There are significant age-related diagnostic issues that are important consid-
erations when working with older couples. Indeed, there is an emerging literature
that recommends various therapist attitudes and procedural enhancements that
clinicians might well consider. These extra "enhancements" can facilitate both
the entry of older couples into therapy and the subsequent effectiveness of thera-
peutic interventions (Gafner, 1987; Stone, 1987; Wolinsky, 1990).
Diagnostic Issues
Diagnostically, one must be aware of changes in mental and physical func-
tioning that are specifically related to the aging process. Moreover, one should be
knowledgeable about the developmental tasks and transitional life events inher-
ent in the postparental and culmination stages of the marital life cycle (Birchler,
1992). Individual spousal changes in mental status, cognitive function, or per-
sonality may indicate a variety of problems, including dementia, depression,
sensory impairment, malnutrition, misuse of substances (e.g., alcohol, street
drugs, medications), drug interactions, and various metabolic conditions. Close
collaboration among health care providers may be important in addressing mul-
tifaceted problems. Additional areas of assessment that might be particularly rel-
evant to older couples presenting for therapy include lifestyle issues (e.g., eating,
drinking, and sleeping habits, recent life disruptions, or a variety of other envi-
ronmental stressors). In the area of sexuality, it is important to distinguish be-
tween normal aging effects on sexual function and sexual dysfunctions that may
be unrelated to aging (refer to the chapter on sexuality in this volume). Psycho-
education may be indicated when older partners experience sexual concerns
that occur in the normal course of aging; formal sex therapy may be appropriate
for other types of sexual dysfunction. The primary determination is how, if at all,
the aging process has caused or exacerbated relationship distress.
Engagement Procedures
Special therapy engagement and therapy facilitation techniques recom-
mended for treating elderly couples take into account certain biases. as well as
emotional and physical needs that elderly clients may have. Any number ofthe
following enhancements may apply to a given case:
1. Be prepared to counter ageism in both the therapist and in the clients.
Do not take the older couple's life experiences, functional status, and
potential for change (or the lack thereof) for granted.
2. Assessment and intervention procedures may need to proceed at a
slower pace to accommodate trust and credibility issues or to compen-
sate for sensory and energy-level impairments. Older couples may be
wary of mental health services and thus seek a greater sense of self-
determination. Go slowly, explain interventions carefully. and give
clients choices whenever possible.
3. Be flexible in considering the logistics of care. It may be that clients
need to be seen in various locations, for varying lengths and total num-
ber of sessions, and be accommodated with special seating, lighting, and
audio enhancements.
4. Older clients may need more work on trust and attitudes before they can
be comfortable with "feeling-talk," conjoint meetings, or certain value-
challenging behavioral interventions.
5. Older clients are likely to be suffering from an interaction of physical

and psychological maladies, (e.g., memory or sensory impairments
causing self-esteem problems, anxiety, depression or irritability).
6. Be aware that older clients often are significantly influenced by impor-
tant others in their lives (e.g., a family physician, the clergy, well-mean-
ing or interfering family members). These agents of influence need to be
taken into account during assessment of the problems and in planning
interventions.
7. Finally, despite these considerations, remember that there is no stereo-
type that fits every elderly couple. Assessments and interventions
should be individualized to meet the existing needs in a given case.
THE FUTURE
A review of the existing literature on marriage and divorce in the elderly

suggests several areas of concern and questions to be addressed by future re-
search. It should be noted that marriages of people reaching later life in the fu-
ture may be considerably different from those represented by the present
cohort. The prevailing divorce rate, remarriages, changes occurring between the
sexes, culturally altered views on marriage itself, and changes in the socioeco-
nomic status of older people-all these factors will significantly impact the life
satisfaction of elderly couples and their families (Askham, 1994).
As with other segments of the population, today there exists great hetero-
geneity among the aged. Many people are in poverty, some are wealthy, while
others who are truly needy may be losing support. To reiterate, economic secu-
rity and good health are the basic prerequisites for successful aging. Sources of
socioeconomic support are in transition; more pressure will be brought to bear
on the family to provide support for the aged (Quiroutte & Gold, 1992). Family
supportive structures prevalent in the past are breaking down. If the current di-
vorce and remarriage rates prevail, it will be even less likely in the future that
the elderly will reside with their children (who increasingly are in remarried
families themselves).
In the future much more definitive and controlled research is needed in the
following areas: adjustment patterns of widows and widowers, alternative fam-
ily forms in later life, quality of life in later years, gender differences (especially
divorce, remarriage, and life satisfaction determinants for males compared to fe-
males), social networks and support systems, family characteristics related to a
higher quality of late life, more representative samples of the elderly (especially
ethnic, racial, and socioeconomic stratifications), spousal variables that predict
husbands' well-being, and additional investigations on marital quality and the
consequences of divorce and remarriage for the older members of our society.
SUMMARY
Marriage and divorce among the elderly is a population phenomenon in a

major transition. Even as the bulk of the u.S. population is aging and is shaping
politics, economics and family relationships significantly, over the past several
decades the institution of marriage has changed as well. On the one hand, given
the prevailing 66% divorce rate, one might conclude that for many. if not the
majority, the expectations for what marriage can and should provide to partici-
pants frequently are not met. On the other hand, we have not as yet discovered
a better model of "permanent" relating, given that the remarriage rate of 75%
suggests that most people try marriage again. Unfortunately, although many
people attempt marriage a second time, these new relationships will just as
likely fail to meet peoples' perceived or actual needs for a marriage. As Stone
(1987) so poignantly states it, the older members of our society are not differ-
ent from us; they are us! The perpetuation of marriage and divorce, in serial
monogamy style, is resulting in an ever more complex and conflicted society.
Children have more and more sets of stepsiblings, stepparents, and stepgrand-
parents. The future, in this respect, is troublesome.
This chapter is written in an attempt to describe the present status of mar-
riage and divorce among older persons. We need a better understanding of the
strengths and developmental accomplishments of long-term marriages, of the
promises and pitfalls associated with remarried older couples, and of the various
and inevitable challenges that we all will face as the years progress. Such knowl-
edge can only help us to prepare for the future and to help older couples as they
seek our assistance in improving the quality oflife in their present circumstances.
Relationship satisfaction, developmental issues, and gender differences that dis-
tinguish older couples' marriages were described along with the requisites for de-
veloping and maintaining long-term intimate relationships. In addition, the life
events, the biological and relationship transitions that accompany the aging
process were contrasted with normal problems and conflicts that may be unre-
lated to aging, but are known to be difficulties for married couples at all ages. A
description of the 7 Cs formulation of marital dysfunction was offered as a con-
ceptual basis for assessment and intervention with older couples. Diagnostic
issues related to the clinical presentation of older couples and specific recom-
mendations for facilitating their participation and benefit from marital therapy
were discussed. Finally, some implications of present trends for the future of
older Americans were presented, along with a number of recommendations for
important research investigations that might better prepare us all for our future.
REFERENCES
Askham, J. (1994). Marriage relationships of older people. Reviews in Clinical Gerontology, 4,
261-268.
Atchley, R (1992). Retirement and marital satisfaction. In M. Szinovacz, D. Ekerdt, & B. Vinick
(Eds.), Families and retirement (pp. 145-158). London: Sage.
Basco, M. A., Birchler, G. R, Kalal, B., Talbott, R., & Slater, M. A. (1991). The clinician rating of
adult communication (CRAC): A clinician's guide to the assessment of interpersonal commu-
nication skill. Journal of Clinical Psychology, 47, 368-380.
Birchler, G. R (1979). Communications skills in married couples. In A. S. Bellack & M. Hersen
(Eds.), Research and practice in social skills training (pp. 273-315). New York: Plenum.
Birchler, G. R. (1983). Marital dysfunction. In M. Hersen (Ed.), Outpatient behavioral therapy: A
clinical guide (pp. 229-269). New York: Grune & Stratton.
Birchler, G. R(1992). Marriage. In V. B. Van Hasselt & M. Hersen (Eds.), Handbook of social devel-
opment: A lifespan perspective (pp. 397-419). New York: Plenum.
Birchler. G. R.. & Fals-Stewart. W. (1994a). Marital dysfunction. In V. S. Ramachandran (Ed.). Ency-
clopedia of human behavior (Vol. 3. pp. 103-113). Orlando. FL: Academic.
Birchler. G. R.. & Fals-Stewart. W. (1994b). The Response to Conflict Scale: Psychometric properties.
Assessment. 1.335-344.
Birchler. G. R.. & Fals-Stewart. W. S. (1996. August). The Marital Relationship Assessment Battery:
A maximal decomposition. Paper presented at the American Psychological Association an-
nual convention. Toronto. Ontario. Canada.
Birchler. G. R. & Fals-Stewart. W. S. (1996). Marital discord. In M. Hersen & V. B. Van Hasselt (Eds.).
Psychological treatment of older adults: An introductory textbook. (pp. 315-333). New York:
Plenum.
Birchler. G. R.. & Schafer. J. (1990. August). Assessment of older couples entering marital therapy.
Paper presented at the American Psychological Association Convention. Boston.
Birchler. G. R.. & Schwartz. L.(1994). Marital dyads. In M. Hersen & S. M. Turner (Eds.). Diagnostic
interviewing (2nd ed .. pp. 277-304). New York: Plenum.
Bowers. I. H .• & Bahr. S. J. (1989). Remarriage among the elderly. In S. J. Bahr & E. T. Peterson (Eds.).
Aging and the family (pp. 85-95). Lexington. MA: Lexington Books.
Brubaker. T. H. (1983). Family relationships in later life. Beverly Hills: Sage.
Butler. R. N. (1974). Successful aging and the role of the life review. Journal of the American Geri-
atric Society. 22. 529-535.
Carter. B.. & McGoldrick. M. (1988). The changing family life cycle (2nd ed.). New York: Gardner.
Castro-Martin. T.. & Bumpass. L. (1989). Recent trends in marital disruption. Demography. 26. 37-51.
Christensen. A .. Jacobson. N. S .• & Babcock. J. C. (1995). Integrative behavioral couple therapy. In N.
S. Jacobson & A. S. Gurman (Eds.). Clinical handbook of marital therapy (2nd ed .. pp. 31-64).
New York: Guilford.
Cole. C. 1. (1986). Developmental tasks affecting the marital relationship in later life. American Be-
havioral Scientist. 29 (4). 389-403.
Cole. C. 1. (1989). Relationship quality in long-term marriages: A comparison of high-quality and
low-quality marriages. In L. Ade-Ridder & C. B. Hennon (Eds.). Lifestyles of the elderly (pp.
61-70). Oxford. OH: Human Sciences.
Condie. S. J. (1989). Older married couples. In S. J. Bahr & E. T. Peterson (Eds.). Aging and the fam-
ily (pp.143-158). Lexington. MA: Lexington Books.
Cubero J.. & Haraff. P. (1965). The significant Americans. New York: Appleton-Century-Crafts.
Dorfman. L. (1992). Couples in retirement: Division of household work. In M. Szinovacz. D. Ekerdt.
& B. Vinick (Eds.). Families and retirement (pp. 159-173). London: Sage.
Fals-Stewart. W. S .• Schafer. J. C.• & Birchler. G. R. (1993). An empirical typology of distressed cou-
ples based on the Areas of Change Questionnaire. Journal of Family Psychology. 7. 307-321.
Fals-Stewart. W. S .• Birchler. G. R.. Schafer. J. C.. & Lucente. S. (1994). The personality of marital
distress: An empirical typology. Journal of Personality Assessment, 62 (2), 223-241.
Gafner, G. (1987). Engaging the elderly couple in marital therapy. American Journal of Family Ther-
apy, 15,305-315.
Gatz. M., Papin, S. J., Pino, C. 0., & VandenBos, G. R. (1985). Psychological interventions with older
adults. In J. E. Birren & K. W. Schaie (Eds.). Handbook of psychology and aging (3rd ed., pp.
404-425). San Diego, CA: Academic.
Gilford, R. (1984). Contrasts in marital satisfaction throughout old age: An exchange theory analy-
sis. Journal of Gerontology. 39, 325-333.
Glick, P. C., & Norton, A. J. (1977). Marrying, divorcing. and living together in the U.S. today. Pop-
ulation Bulletin, 32, 1-39.
Goldberg, J. R. (1992). The new frontier: Marriage and family therapy with aging families. Family
Therapy News, 23 (4), 1.
Gottman. J. M., Notarius. C.• Gonso. J.• & Markman. H. (1976). A couple's guide to communication.
Champaign. IL: Research Press.
Hammond, D. B. (1989). Love, sex, and marriage in the later years. In E. S. Deichman & R. Kociecki
(Eds.). Working with the elderly (pp. 255-273). Buffalo. NY: Prometheus Books.
Heiman, J. R. (1986). Treating sexually distressed marital relationships. In N. S. Jacobson & A. G.
Gurman (Eds.), Clinical handbook of marital therapy (pp. 361-384). New York: Guilford.
Hennon. C. B. (1983). Divorce and the elderly: A neglected area ofresearch. In T. Brubaker (Ed.).
Family relationships in later life (pp. 149-172). Beverly Hills. CA: Sage.
Hess. B. B..& Markson. E. W. (1986). Growing old in America (3rd ed.). New Brunswick. NJ: Transi-
tion Books.
Jacobson. N. S.. & Margolin. G. (1979). Marital therapy: Strategies based on social learning and be-
havior-exchange principles. New York: Brunner/Mazel.
Karney. B. R.. & Bradbury. T. N. (1995). The longitudinal course of marital quality and stability: A
review of theory. method. and research. Psychological Bulletin. 118. 3-34.
Lauer. R.. Lauer. J.. & Kerr. S. (1990). The long-term marriage: Perceptions of stability and satisfac-
tion. International Journal of Aging and Human Development. 31. 189-195.
Lee. G. (1986). Marriage and aging. In B. B. Hess & E. W. Markson (Eds.). Growing old in America
(3rd ed .• pp. 361-368). New Brunswick. NJ: Transition Books.
Lee. G. (1988). Marital satisfaction in later life: The effects of non-marital roles. Journal of Marriage
and the Family. 50, 775-783.
Levenson. R. W., Carstensen. L. 1.. & Gottman. J. M. (1993). Long-term marriage: Age. gender. and
satisfaction. Psychology and Aging. 8. 301-313.
Levenson. R. W.• Carstensen, 1. 1.. & Gottman. J. M. (1994). Influence of age and gender effect on af-
fect. physiology. and their interrelations. Journal of Personality and Social Psychology, 67 (1).
56-68.
Lewis. J. M. (1988). The transition to parenthood: II. Stability and change in marital structure. Fam-
ily Process, 27. 149-165.
Lewis. J. M .• Owen. M. T.. & Cox. M. J. (1988). The transition to parenthood: III. Incorporation of the
child into the family. Family Process, 27. 411-421.
Lewis. R. A.. & Spanier. G. B. (1979). Theorizing about the quality and stability of marriage. In W. R.
Burr. R. Hill, F. I. Nye. & I. 1. Reiss (Eds.). Contemporary theories about the family: Research-
based theories (pp. 268-294). New York: Free Press.
Miller. B. C. (1976). A multivariate developmental model of marital satisfaction. Journal of Marriage
and the Family. 38. 643-657.
Mindel, C. H. (1986). The elderly in minority families. In B. B. Hess & E. W. Markson (Eds.). Grow-
ing old in America (3rd ed .• pp. 369-386). New Brunswick. NJ: Transition Books.
Morgan. L. A. (1992). Marital status and retirement plans. In M. Szinovacz. D. Ekerdt. & B. Vinick
(Eds.). Families and retirement (pp. 114-126). London: Sage.
Nadelson. C.. Polonsky. D. C.• & Mathews. M. A. (1984). Marriage as a developmental process. In C.
Nadelson & D. C. Polonsky (Eds.), Marriage and divorce: A contemporary perspective
(pp.127-141). New York: Guilford.
Neidhardt, E. R.. & Allen. J. A.(1993). Family therapy with the elderly. Newbury Park. CA: Sage.
Nichols. W.C. (1988). Marital therapy. New York: Guilford Press.
Notarius. C. I.. & Markman, H. (1993). We can work it out: Making sense of marital conflict. New
York: Putnam·s.
Peterson. E. T.. & Bahr. S. J. (1989). Epilogue: Prospects for the future. In S. J. Bahr & E. T. Peterson
(Eds.). Aging and the family (pp. 305-313). Lexington. MA: Lexington Books.
Quirouette. C.. & Gold, D. P. (1992). Spousal characteristics as predictors of well-being in older cou-
ples. International Journal of Aging and Human Development. 34 (4). 257-269.
Rollins, B. C., & Cannon, K. L. (1974). Marital satisfaction over the family life cycle: A reevaluation.
Journal of Marriage and the Family. May. 271-282.
Rosenberg, I. I. (1989). Love and marital problems in the elderly. University Service News. 3 (2). 3.
Spanier. G., Lewis, R.. & Cole, C. (1975). Marital adjustment over the family life cycle: The issue of
curvilinearity. Journal of Marriage and the Family. 37, 263-276.
Stone, J. D. (1987). Marital and sexual counseling of elderly couples. In G. R. Weeks & L. Hoff (Eds.),
Integrating sex and marital therapy: A clinical guide (pp. 221-244). New York: Brun-
ner/Mazel.
Stuart, R. B. (1980). Helping couples change. New York: Guilford.
Swenson, C. H., Eskew, R. w., & Kohlhepp, K. A. (1981). Stage offamily life cycle, ego development,
and the marriage relationship. Journal of Marriage and the Family, 43, 841-853.
Szinovasz. M., Ekerdt, D. J.. & Vinick. B. H. (1992). Families and retirement. Beverly Hills, CA: Sage.
Traupmann. J.. & Harfield, E. (1983). How important is marital fairness over the lifespan? Interna-
tional Journal of Aging and Human Development. 17 (2), 89-101.
Troll, 1. E. (1986). Marriage. In 1. E. Troll (Ed.). Family issues in current gerontology (pp. 1-13).
New York: Springer.
Uhlenberg, P., Cooney, T., & Boyd, R. (1990). Divorce for women after midlife. Journal of Gerontol-
ogy, 45 (1), S3-S11.
Vinick, B., & Ekerdt, D. (1992). Couples view retirement activities: Expectation versus experience.
In M. Szinovacz, D. Ekerdt, & B. Vinick (Eds.), Families and retirement (pp. 129-144). London:
Sage.
Weiss, R. 1., & Birchler, G. R. (1975). Areas of Change Questionnaire. Unpublished manuscript,
University of Oregon, Eugene.
Wolinsky, M. A. (1990). A heart of wisdom: Marital counseling with older and elderly couples. New
York: Brunner/Mazel.
Wynne, 1. C. (1984). The epigenisis ofrelational systems: A model for understanding family devel-
opment. Family Process, 23, 297-318.
CHAPTER 21
Family Caregiving
Stress, Coping, and Intervention
DOLORES GALLAGHER-THOMPSON, DAVID w. COON,

PATRICIA RIVERA, DAVID POWERS,
AND ANTONETTE M. ZEISS
INTRODUCTION
At present, more than 4 million adults over the age of 65 years receive some
type of personal care from family members. This figure is expected to increase
as the nation's population of older adults grows to 67.5 million by the year
2050 (U.S. Senate, 1991). In such situations, the care recipient frequently ben-
efits from the physical, emotional, and financial support provided by the fam-
ily caregiver. However, the personal consequences to the caregiver of fulfilling
this responsibility have received much attention in the research literature.
This chapter will review the findings from studies with family care providers.
We begin with a historical overview of the characteristics of individuals who
comprise the majority of caregivers in this country, and review the problems,
stresses and hardships they experience. Next, we review theoretical models
that have been proposed to explain the process of caregiver distress and its in-
teraction with moderating variables. Then, we examine the various psycholog-
ically oriented treatments and forms of intervention currently available, and
address issues of their efficacy. Finally, we provide a brief review of the grow-
ing literature on special caregiving populations, with particular emphasis on
DoLORES GALLAGHER-THoMPSON • Older Adult Center, Veterans Affairs Health Care System, Palo Alto,
California 94304 and Stanford University School of Medicine, Stanford, California. DAVID W. COON,
PATRICIA RIvERA AND DAVID POWERS • Older Adult Center, Veterans Affairs Health Care System, Palo
Alto, California 94304. .ANroNETrE M. ZEIss • Thaining and Program Development, Psychology Ser-
vice, and Interprofessional Team Thaining and Development Program, Veterans Affairs Health Care Sys-
tem, Palo Alto, California 94304.
469
470 Dolores Gallagher-Thompson et al.
the unique needs and concerns of male caregivers and caregivers of various
ethnic or minority backgrounds. The chapter closes with recommendations for
future research.
FAMILY CARE GIVING IN HISTORICAL

PERSPECTIVE
Although public concern for older persons has existed since the founding
of this country, their attention and care has largely been a private family matter.
In the mid-1800s, individual states began to include family welfare laws in
their statutes, outlining a standard of care required of all citizens toward their
elderly kin. The Social Security Act of 1930, however, assigned more of the task
to public programs and resources, thereby allowing individuals to reduce the
level of personal responsibility for care of aged relatives (Schorr, 1980). More re-
cently, demographic, social, and economic pressure have created a shift back to-
ward personal responsibility, and individuals have found themselves in the
role of "caregiver" to spouses, elderly parent(s), grandparents, or even friends
and neighbors.
Although medical and scientific advances have contributed to increased
longevity in this country, it was the increase in births during the 1920s and the
postwar "baby boom" that had the greatest impact on aging in this nation. The
drop in birthrates in the 1960s contributed to a drastic shift in the proportion of
old to young citizens (U.S. Senate, 1991), making it more likely for adult chil-
dren of today to have living parents and, frequently, grandparents. The in-
creased divorce rate denies older individuals who have not remarried spousal
support (a primary source of assistance for frail elders). In divorce situations,
more caregiving responsibility may fall on adult children (Cicirelli, 1983), who
must struggle to care for two parents who do not live together. Finally, 62% of
American women between the ages of 45 and 54 work full-time (U.S. Depart-
ment of Labor, 1990). This segment of the population is likely to assume the
role of family caregiver to an aging parent; the requirements inherent in the
dual role of paid employee and unpaid caregiver can contribute to feelings of
burden and distress. Moreover, those women who are also mothers shoulder the
burden of a third role and may experience even greater stress with these com-
peting demands (Brody, 1990). One might infer that elder abuse or neglect
could result from the role overload experienced by these caregivers, but the
phenomenon most often seen is the emotional and physical toll paid by family
caregivers themselves.
WHO ARE THE INFORMAL CAREGIVERS?
Because the processes of aging and debilitation tend to be gradual, the pro-
vision of assistance usually begins with the individual closest in physical prox-
imity to the elder; thus, spouses are natural primary caregivers (Zarit, Birkel, &
MaloneBeach, 1989). In situations in which there is no spouse, evidence points
to the existence of a hierarchical pattern of responsibility, with primary duties
Family Caregiving 471
going to the adult female child, then the adult male child, and finally, other
family members (Cantor, 1983). A 1982 long-term care survey found that 22%
of caregivers sampled were spouses, 30% were children (83% of whom were
daughters), and 18% were formal, or paid, caregivers. Indeed, up to three quar-
ters of the caregivers surveyed shared households with a frail elder (R. Stone,
Cafferata, & Sangl, 1987), and the majority of unmarried or divorced adult chil-
dren cited financial hardships as primary reasons for co-residence (Brody,
Litvin, Hoffman, & Kleban, 1995; Cutler & Coward, 1992). Other factors that
help to determine whether one will accept the responsibility of caregiving in-
clude presence of competing role demands, such as employment and marital
status, as well as financial status and prior relationship history with the care re-
cipient (Arling & McAuley, 1983; Brody et aJ., 1996).
Responsibilities associated with caregiving of an elderly individual are nu-
merous and may vary from simple errands which take minutes, to such physi-
cally and emotionally challenging tasks as bathing or toileting a confused and
frail individual. Although the type of assistance provided depends on the el-
der's level of disability, caregivers generally provide as-needed assistance in the
areas of (1) personal service provision, such as help with instrumental activities
of daily living (e.g., balancing the checkbook and supervising medication us-
age), along with more intimate forms of personal care including dressing, feed-
ing, and bathing, (2) identification of, and linkage to, formal services such as
senior day care and transportation, (3) financial support, and (4) emotional sup-
port through regular contact, company, and conversation (Horowitz, 1985).
WHAT IS THE PSYCHOLOGICAL IMPACT

OFCAREGMNG
For some individuals, caring for a parent and the sense of reciprocating the
nurturance and care once provided by that parent can be very rewarding (Al-
tholz, 1991). National estimates show that approximately 75% of caregivers say
caregiving makes them feel useful (U.S. House of Representatives, 1987) and a
growing literature suggests that caregiving can lead to personal rewards and sat-
isfaction (Genevay, 1994; Lawton, Moss, Kleban, Glicksman, & Rovine, 1991).
For example, people may remain caregivers over an extended period of time for
several positive personal outcomes, including the following: caregiving may
contribute to self-worth, build self-confidence, and provide companionship
(Schulz, Tompkins, & Rau, 1988).
A far greater number of caregivers, however, report negative feelings as a re-
sult of the increased responsibility of caring for a disabled or impaired relative.
Anger, frustration, and anxiety are common symptoms of caregiver distress and
clinical levels of depression in caregivers of Alzheimer's patients have been re-
ported in several studies (reviewed in Schulz, Visintainer, & Williamson, 1990).
In addition, use of psychotropic medications among caregivers is higher than
that of their noncaregiving counterparts (see also updated review by Schulz,
O'Brien, Bookwala, & Fleissner, 1995).
Prevalence of depression among caregivers of impaired elders reported in
the caregiving literature ranges from about 20% to more than 80%. However,
prevalence rates of clinical diagnoses of depression determined by structured

clinical interviews are often noticeably lower than rates derived from self-
report inventories that focus on depressive symptoms. Still, caregiving studies
incorporating structured clinical interviews, such as the Schedule for Affective
Disorders and Schizophrenia (SADS; R. Spitzer & Endicott, 1978), the Diagnos-
tic Interview Schedule (DIS; Robins, Helzer, Croughan, & Ratcliff, 1981), and
the Structured Clinical Interview for DSM-IIJ-R (SCm; R. 1. Spitzer, Williams,
Gibbon, & First, 1992) have found significantly higher rates of clinical depres-
sion among caregivers compared with the general adult population. For exam-
ple, in a study of 68 spousal caregivers to individuals with Alzheimer's disease,
more than 40% met current criteria for a depressive disorder as measured by
the SADS, and another 40% of this sample of caregivers met the same criteria
for a time period earlier in their caregiving situation (Coppel, Burton, Becker, &
Fiore, 1985). Drinka, Smith and Drinka (1987) found even higher rates of de-
pressive disorders in their study of caregivers for demented patients. Of the 117
caregivers assessed, 83% met DSM-III (American Psychiatric Association, 1980)
diagnostic criteria for major depression. However, caregivers in this sample pro-
vided assistance for patients unable to follow treatment regimens prescribed by
specialty clinics. This uniqueness suggests an extra burden for the caregivers,
which may have contributed to the high rate of reported depressive disorders.
More recently, Redinbaugh, MacCallum, and Kiecolt-Glaser (1995) investi-
gated recurrent syndromal depression, as identified by Structured Clinical In-
terview-Nonpatient version (SCm-NP) (Riskind, Beck, Berchick, Brown, & Steer,
1987; Spitzer, Williams, Endicott, & Gibbon, 1987). Syndromal depression in
their project included diagnoses of major depression, dysthymia, or depressive
disorder not otherwise specified. Among their sample of 103 caregivers for fam-
ily members with progressive dementia, 53% of these caregivers reported a syn-
dromal depressive disorder at some point over 3 years of caregiving.
Rate of depression seems to remain higher among caregivers than the gen-
eral population regardless of whether or not they feel they need help for their
distress. Gallagher and her colleagues used the SADS to describe their sample
of 115 help-seeking caregivers recruited for a psychoeducational intervention
(Gallagher, Rose, Rivera, Lovett, & Thompson, 1989). Of these caregivers, 46%
were diagnosed with major, minor, or intermittent depressive disorders; an ad-
ditional22% ofthese participants reported some depressive features. As a part
of the same study, this team of researchers recruited an additional 58 nonhelp-
seeking caregivers from an Alzheimer's disease study, and discovered that 18%
of these similarly assessed nonhelp seekers met criteria for depression. More
than one third of this nonhelp-seeking group also presented with some depres-
sive symptoms. Even though a larger proportion of help seekers than nonhelp
seekers were diagnosed with depression, the proportion of depressed nonhelp-
seeking caregivers is still as much as ten times greater than prevalence figures
for major depression reported among adults in general (Blazer, Hughes &
George, 1987; Koenig & Blazer, 1992).
A more striking picture of the prevalence of depression appears when care-
givers are contrasted with comparison groups. Dura, Stukenberg, and Kiecolt-
Glaser (1991) administered the scm to a group of 78 adult children caring for
their demented parents and contrasted these results with scm ratings from a
group of 78 comparison subjects of similar age and other demographic charac-

teristics. At time of assessment, 18% of the caregivers presented with clinical
depressive disorders versus 0% of the comparison group. Another 26% of these
caregivers also met diagnostic criteria for a depressive disorder at some earlier
point during the time they provided care, as contrasted with only 4% of the
comparison subjects matched on equivalent time periods. These differences be-
tween subjects and matched comparison groups hold when subjects are as-
sessed more than once during the course of caregiving. In a study of 69 spousal
caregivers and matched noncaregiving adults, 25 % of the caregivers as opposed
to 0% of the noncaregivers met criteria for a diagnosis of a depressive disorder
at an initial assessment point, and 32% of these caregivers and 6% of the com-
parison subjects met criteria for a depressive disorder at some point during the
next 13 months (Kiecolt-Glaser, Dura, Speicher, Trask, & Glaser, 1991).
Similarly, Russo, Vitaliano, Brewer, Katon, and Becker (1995) used another
diagnostic interview, the Diagnostic Interview Schedule Version III-R (DIS;
Robins et al., 1981), to measure depressive and anxiety disorders among a
group of spouse caregivers (N = 82) and a group of demographically matched
controls. During the time they provided care, 27% of the caregivers met crite-
ria for either a depressive or anxiety disorder and 20% had a major depressive
episode. In contrast, only 10% of the noncaregiving controls met criteria for a
depressive or anxiety disorder, and only 7% had an established major depres-
sive episode across similar time periods. The current prevalence of major de-
pression in the same group of caregivers ranged from 7.3% at baseline to 9.8%
approximately 18 months later, whereas the prevalence rate ranged from 0% to
1.2% among controls. Moreover, caregivers with past psychiatric disorders
were found to be twice as likely to have a recurrence or relapse after onset of pa-
tient illness as matched controls with previous disorders assessed at compara-
ble time frames.
Standardized self-report inventories, such as the Center for Epidemiologic
Studies Depression Scale (CES-D; Radloff, 1977) and the Beck Depression In-
ventory (BDI; Beck, Rush, Shaw, & Emery, 1979), are also used to assess depres-
sion and depressive symptoms in caregivers to elders. Most caregiving studies
using the CES-D report means between 14 and 18, with scores of 16 or above in-
dicating that an individual is at risk for clinical depression (e.g. Baumgarten et
al., 1992; Pruchno, Kleban, Michaels, & Dempsey, 1990). The average reported
CES-D score as well as the proportions of caregivers over the cutoff score of 16
are often well above the typical population means (7.4 to 9.4) and proportions
(15% to 20%) described by various epidemiological studies (Futterman,
Thompson, Gallagher-Thompson, & Ferris, 1995). For example, Baumgarten
and colleagues (1992) using the CES-D with a group of 103 primary caregivers
of dementia patients and a group of none aregiving spouses discovered 38.8% of
these caregivers fell above the cutoff score. This is two times the percentage
found in the noncaregiving community samples (16.5%). These means and pro-
portions are even higher when caregivers are recruited from either home health
service agencies or waiting lists for respite services (e.g., Mohide et al., 1990;
Robinson, 1989; Shields, 1992).
Caregiving studies using the Beck Depression Inventory (BDI) have also re-
ported higher means and proportions for caregivers than those found in the gen-
eral population. For instance, a study that compared caregivers of cognitively

versus functionally impaired elders revealed that almost 50% of caregivers to
cognitively impaired care receivers and almost 40% of the caregivers to func-
tionally impaired care receivers scored above normal Bm cutoff scores, indicat-
ing current depressive symptoms (Gallagher, Wrabetz, Lovett, DelMaestro, &
Rose, 1989). Vitaliano, Russo, Young, Teri, and Maiuro (1991) found that 34.2%
of spousal caregivers to individuals with Alzheimer's disease scored above the
Bm's mild depression cutoff at baseline; this proportion did not change sig-
nificantly at a 15- to 18-month follow-up assessment. Similarly, Dura and col-
leagues (1991), in a study of adult children caring for demented parents,
determined that mean Bm scores in this group of caregivers were significantly
higher than a matched group of noncaregiving controls.
In sum, prevalence rates for depression among caregivers of elders are im-
pressive, whether these rates are determined by structured interview or self-
report. Yet, a sizable proportion of caregivers actually do report few depressive
symptoms or feelings. Furthermore, a subgroup of these caregivers report very
little psychological distress, despite the fact that they complain of caregiver
stress and volunteer for various interventions designed to reduce their per-
ceived distress (Zarit, 1990; Zarit, Anthony, & Boutselis, 1987). Variability in
prevalence rates reported and the differences in people's experience of the care-
giving process has generated a large caregiving literature designed to identify
and discuss factors that may contribute to caregiver distress and well-being.
Several of these studies have produced mixed results but other findings have
been consistently supported by the literature.
Research results from studies exploring the caregiver's relationship to the
frail elder imply that both spousal and adult offspring caregivers can experience
significant depression. Yet on the whole, intrahousehold caregivers, especially
spouses, are more likely to experience distress from extended caregiving than
adult offspring caregivers living apart from elders (Baumgarten et a1., 1992;
George & Gwyther, 1986; Zarit & Whitlatch, 1992). Such level of depression may
be further exacerbated by the quality of the caregiver-care receiver relationship
prior to the onset of the elder's illness. A high degree of positive attachment be-
tween caregiver and patient can presumably contribute significantly to the ex-
perience of loss and grief in the altered relationship between patient and
caregiver. Alternatively, a low level of attachment. or even a conflicted rela-
tionship between caregiver and patient may produce negative affect such as
anger and resentment (Robinson, 1989; Schulz & Williamson, 1991). It is possi-
ble that caregivers in both scenarios may manifest their negative affect through
depressive symptomatology, but further exploration of the caregiver-patient
premorbid relationship is warranted.
The caregiving literature overwhelmingly supports the notion that caregiv-
ing can adversely affect a caregiver's psychological well-being regardless of the
elder's particular illness or disability. Further, many studies suggest that caring
for an elder with more frequently occurring problem behaviors places the care-
giver at an even higher risk for depression (Baumgarten et al., 1992; Mittelman et
al., 1994; Schulz & Williamson, 1991). However, the impact of other patient ill-
ness characteristics on caregivers is not as clear. The majority of studies indicate
that neither the amount of assistance provided to the elder nor the severity of his
or her cognitive impairment is directly explanatory of caregiver depression (e.g.,

Clipp & George, 1990; Deimling & Bass, 1986; Dura, Stukenberg, & Kiecolt-
Glaser, 1990; Dura et al., 1991; Gallagher et al., 1989; Kiecolt-Glaser et al., 1991;
Pruchno & Resch, 1989; Russo et al., 1995; Schulz & Williamson, 1991). How-
ever, a smaller, but still substantial, group of studies have reported findings sup-
porting these relationships (Baumgarten et al., 1992; Coppel et al., 1985; W. E.
Haley, Levine, Brown, Berry, & Hughes, 1987; Russo et al., 1995).
The length of time providing care may contribute to caregiver depression,
but the extent and direction of the relationship is uncertain. At first, we might
expect that an increasing length of time spent caregiving would wear caregivers
down, increase their vulnerability, and exacerbate negative affective states (e.g.,
Baumgarten et al., 1992: George & Gwyther, 1986), but several studies have not
found this to be the case (e.g., Draper, Poulos, Cole, Poulos, & Ehrlich, 1992;
Kiecolt-Glaser et al., 1991). In fact, an additional amount of time spent in the
caregiving role may actually influence grief and loss processes, including
preparation for the frail elder's death, or it may strengthen coping skills and so-
cial resources that result in caregiver adaptation (Mullan, 1992; Norris & Mur-
rell, 1987; Pearlin, Mullan, Semple, & Skaff, 1990).
Another cluster of findings supports the contention that being an older
Caucasian female (Blazer, 1990; Evans, Copeland, & Dewey, 1991; Mirowsky &
Ross, 1990; Williamson & Schulz, 1992) with few economic resources (George,
1983; Mirowsky & Ross, 1990), who is experiencing significant life stressors
and who also has few social supports (Dean, Kolody & Wood, 1990; George,
1983; Mirowsky & Ross, 1990; Russell & Cutrona, 1991) increases the risk of
developing psychological symptoms of distress. Although there are a few ex-
ceptions (see, e.g., Dura et aI., 1991; Shields, 1992), caregiving wives and
daughters generally report more depression and other psychological distress
than comparable husbands and sons (Anthony-Bergstone, Zarit, & Gatz, 1988;
Gallagher et al., 1989; Horowitz, 1985; Lieberman & Fisher, 1995; Young & Ka-
hana, 1989). Although our understanding ofthis gender discrepancy is still un-
clear, socialization may playa role by permitting women to more freely
express their feelings and by promoting different conceptualizations between
the sexes of the meaning, roles, and tasks of caregiving (Horowitz, 1985; Miller,
1987; Pruchnol et al., 1990).
Characteristics and qualities of caregivers' social resources may help in
managing the situation or help buffer them from negative effects of caregiving. In
general, caregiver perceptions of greater amounts of available support, adequacy
of social support, and satisfaction with the support received have been reported
to be associated with less depression and other negative affective states (Fiore,
Coppel, Becker, & Cox, 1986; Mittelman et al., 1994; Oxman, Freeman, Man-
heimer, & Stukel, 1994). Similarly, particular domains or types of social support,
including larger amounts of direct assistance and positive feedback from others
as well as higher numbers of self-reported recreational interactions, have also
been associated with lower levels of depression. In contrast, two other support
characteristics investigated in the literature, namely, a greater need for social
support and increased negative interactions with others, appear to be related to
more caregiver psychological distress (MaloneBeach & Zarit, 1995; Redinbaugh
et aI., 1995; Rivera, Rose, Futterman, Lovett, & Gallagher-Thompson, 1991;

Thompson, Futterman, Gallagher-Thompson, Rose & Lovett, 1993).
In addition to caregivers' social resources, their psychological resources,
including the coping strategies they use to handle the caregiving situation, ap-
pear to be related to both the quality and quantity of distress experienced
(Coppe et aI., 1985; W. E. Haley, Levine, Brown, & Bartolucci, 1987; W. E. Haley,
Levine, Brown, Berry, & Hughes. 1987; Pruchno & Resch, 1989). On the one
hand, caregivers who use problem-focused coping strategies to reassess situa-
tions, seek out alternatives, and take steps to change how stressors are handled
seem to experience less depression and more positive caregiver well-being. On
the other hand, use of emotion-focused coping strategies that encourage avoid-
ance, escape, and fantasy in response to real and unavoidable caregiver stres-
sors seems to be less effective in reducing depression and other negative affect
(Barusch, 1988; W. E. Haley et aI., 1987; Pruchno & Resch, 1989; Quayhagen &
Quayhagen, 1989; Vitaliano et al., 1991).
In an investigation related to these findings on coping strategies, Hooker,
Frazier, and Monahan (1994) addressed the issue of personality and coping
style in a study of 50 Alzheimer spousal caregivers. Caregivers scoring high on
neuroticism tended to use emotion-focused coping strategies that are associ-
ated with depression and increased interpersonal conflict, but those scoring
high on extroversion used problem-solving approaches. Because coping strate-
gies are easily taught. it may be useful to identify those caregivers who are at
higher risk and provide them with coping skills training in the early stages of
their caregiving.
IMPACT OF CARE GIVING ON

PHYSICAL HEALTH
Fengler and Goodrich (1979) have referred to caregivers as "hidden pa-

tients," suggesting that caregivers experience significant physical health prob-
lems as a result of their exposure to the consistent stress of caregiving. Yet, the
research examining caregiving effects on physical health is somewhat limited.
Generally, increased emotional distress is often found to be associated with
poorer self-reported physical health (Baumgarten et aI., 1992; Draper et aI.,
1992; Mittelman et al., 1994; Schulz et al., 1990; Schulz et aI., 1995; Wright et
aI., 1993). However, we should keep in mind that physical health effects may
not become evident until quite some time after caregiving ends (Schulz et aI,
1990). In a study comparing the health status of caregivers to noncaregivers,
Kiecolt-Glaser and colleagues (1987) found caregivers to have weaker immune
responses than noncaregivers. In a recent review of physical health outcome
studies of Alzheimer's disease caregivers, Schulz and colleagues (1995) con-
cluded that although caregivers report their health to be worse than that of their
noncaregiving peers, the relationships among their perceived health and their
actual symptoms, behavior, or use of health care services are tenuous. The stud-
ies reviewed did, however, support the relationship between socioeconomic
hardship (and its associated stressors such as high perceived stress, low life sat-
isfaction) and negative health outcomes. Finally, these studies evidenced a pat-
tern of health effects specific to caregiving such that caregivers of patients ex-
hibiting cognitive impairments evidenced greater physical health problems,
whereas those caring for patients with problem behaviors were more likely to
experience psychiatric morbidity.
PSYCHOLOGICALLY ORIENTED
INTERVENTIONS FOR TREATMENT
OF CAREGIVER DISTRESS
As the previous section has clearly shown, most caregivers experience a

considerable amount of psychological distress during their tenure in the care-
giving role, with the most prominent negative emotions being depression, frus-
tration or anger, and anxiety. Other feelings, such as guilt, loneliness, fear, and
apprehension about the future, have also been reported in some studies. In fact,
clinical experience suggests that most caregivers experience a wide range of
negative affects over the course of time. In an effort to address these unpleasant
mood states, and at the same time encourage caregivers to give and get support
from one another, the Alzheimer's disease (AD) support group movement was
started over a decade ago. The program was initiated by a woman in Minnesota
whose husband had AD and who felt extremely alone in her efforts to give him
care. This movement has grown tremendously, so that now there are AD chap-
ters and support groups in most towns and cities throughout the United States.
as well as in most countries of the world. The success of the AD movement
spawned development of other self-help groups based on type of disability;
there are now support groups for caregivers of persons with Parkinson's disease,
for those who have suffered multiple strokes (or multiinfarct dementia), or for
brain-damaged adults in whom the cause might not be easily determined. How-
ever, despite the grassroots success of these groups, few empirical studies have
been conducted to evaluate the impact of support group participation on the
psychological status of family caregivers. Gonyea (1989), in a review of avail-
able literature, found that most participants rated the group experience as help-
ful, but more objective measures of psychological distress, such as self-report
scales for depressive symptoms or frustration tolerance, were rarely used. In ad-
dition, there is some evidence that support groups meet the needs of caregivers
in terms of gaining knowledge about the particular disease and its likely course
over time (Toseland, Rossiter, & Labrecque, 1989). However, there is much less
evidence that membership in a support group helps reduce psychological dis-
tress and perceived burden, or that caregivers attending support groups gain
skills to manage their situations more effectively (Dura et 01.,1991; Toseland et
al. 1989).
One might argue that support groups serve a valuable function for most
caregivers at some stage in the process. However, by themselves, they may not
be adequate to help caregivers feel better about themselves or how they are
managing, because the focus of support groups is simply on sharing feelings,
not on sharing solutions or strategies for improving quality of life. In some in-
stances, support groups may actually be of little value (for example, when the
caregiver is in acute distress and needs to know how to deal with his or her
strong emotions). Further, as with any intervention, quality of the experience

varies greatly according to the personalities of the other participants and the
leader (if there is one). Finally, some caregivers are not comfortable expressing
themselves in front of a group, no matter how supportive the group tries to be,
so that the group venue is likely to be of little benefit. For such caregivers, in-
dividual counseling or therapy (depending on the nature and severity of the
problem) would be needed.
However, for most caregivers who regularly attend support groups and who
do benefit, the time comes when something else seems to be needed so that they
can cope more effectively with the stresses and strains of daily caregiving re-
sponsibilities and a deteriorating family member. To address these needs, sev-
eral research groups have focused on the development of psychoeducational
programs using specific themes, such as "coping with depression," "coping
with frustration," or "coping with stress." Under these rubrics, certain specific
skills are taught, usually in a small group or class format, with a relatively small
number of participants, to encourage active learning and mastery of cognitive
and behavioral coping strategies.
Interventions focused on teaching self-management skills to family care-
givers have included such strategies as relaxation training, teaching problem-
solving skills, or teaching methods for increasing everyday pleasant events
(Greene & Monahan, 1989; W. E. Haley, 1989; Lovett & Gallagher, 1988; Whit-
latch, Zarit, & von Eye, 1991). Similar to traditional psychotherapy groups, they
are generally small in number: 8 to 10 participants who sign up for a given
number of sessions in a closed-end format. Participants are encouraged to share
thoughts and feelings and to participate actively through role playing, skill
demonstrations, and "homework" opportunities that encourage the practice of
new skills outside the group or class setting. In general, those programs that
teach a very specific set of skills (such as anger management), rather than a
broad array of skills (such as problem solving), report more improvement in
terms of reduction in depression and increased well-being in caregivers (Gal-
lagher-Thompson & DeVries, 1994; Lovett & Gallagher, 1988). In general, such
short-term, highly focused programs have been effective in reducing caregivers'
stress and related negative emotions when levels of distress were high at the
outset. Less improvement has been noted among caregivers who were less dis-
tressed to begin with, possibly reflecting the fact that the latter had less room for
change. Moreover, even when measures of distress did not change significantly
over time, caregivers have reported high levels of satisfaction with these inter-
ventions (Toseland et a1., 1989), along with increased self-efficacy and control
over certain aspects oftheir situation (Steffen, Gallagher-Thompson, Zeiss, &
Willis-Shore, 1994).
For those caregivers experiencing more distress, such as those in an
episode of major depression or those who are actively abusing or neglecting the
elder care receiver, individual counseling or psychotherapy may be indicated.
Case reports by Rose and DelMaestro (1990), Kaplan and Gallagher-Thompson
(1995), and Dick and Gallagher-Thompson (1995) describe use of methods such
as brief psychodynamic therapy or short-term cognitive-behavioral therapy for
such individuals; these case studies report excellent results. Few empirical
studies have been conducted that evaluate efficacy of psychotherapy with fam-
ily caregivers, but those that have are encouraging. For example, Gallagher-
Thompson and Steffen (1994) found that both brief psychodynamic and brief
cognitive-behavioral therapy were effective in significantly reducing clinical
levels of depression in a sample of more than 60 family caregivers. Similarly,
Toseland and Smith (1990) demonstrated the benefits of individual therapy for
caregivers' subjective well-being, particularly for subjects with professional
therapists as compared to those meeting with peer counselors.
An individually based behavioral approach trained caregivers in principles
and techniques that could be used in the home to manage the troublesome be-
haviors of their impaired relative more effectively (Pinkston & Linsk, 1984).
They taught caregivers to monitor and then change problematic behaviors
through reinforcement, cueing, and shaping of more appropriate behaviors (e.g.,
socialization, dressing, toileting) and reported excellent success with this pro-
gram. Teri and colleagues have termed this the "A-B-C" approach to behavioral
management, referring to the links between antecedent events, behavioral re-
sponses, and emotional consequences. They emphasize teaching new behav-
ioral responses and better management of the antecedent events that trigger
problematic behaviors, particularly in demented elders (see Teri & Logsdon,
1991; Teri & Uomoto, 1991, for further description of this approach).
Teri and Gallagher (1991) have also described suggested interventions that
caregivers could be taught to administer that could be utilized to treat depres-
sion in dementia victims. This approach is suggested not only to benefit the
care receiver, but is also thought to benefit the caregiver in two ways. First. the
caregiver goes through the same activities, designed to dispel depression and
create positive mood. as the care receiver; caregivers using this approach have
been shown to respond with reduced depression. Second, if the care receiver
is less depressed, some tasks of caregiving may be easier, such as getting the pa-
tient up and dressed. feeding the patient, and so forth.
Several informative reviews have been published in the past few years that
debate the relative efficacy of psychosocial interventions (in general) and psy-
choeducational interventions (in particular) for improving the psychological
function of family caregivers. These reviews include those by Bourgeois.
Schulz, Burgio (1996), Gallagher-Thompson (1994b), Knight, Lutzky, and Ma-
cofsky-Urban (1993), and Toseland and Rossiter (1989). The reviewers disagree
as to which interventions are most effective for reducing caregivers' burden
and/ or other indices of psychological distress. However, in general, they report
that individual psychosocial interventions have been at least "moderately" ef-
fective with distressed and depressed caregivers, whereas group interventions
had more "modest" effects. with greater variability in responsiveness.
This body of findings suggests that the next generation of caregiver efficacy
research should focus on which interventions are most effective for caregivers
with certain characteristics (or individual difference variables) at the beginning
oftreatment as assessed during an intake process. As Snow (1991) has very co-
gently argued, it is only by carefully studying aptitude by treatment interaction
(AT!) effects that we will have an empirical basis for deciding who is most
likely to benefit from a given intervention.
Data from a recently completed study by our group confirm the value of
this approach. By examining the interaction of anger expression style and type
480 Dolores Gallagher-Thompson et aI.
of caregiver class (emphasizing controlling one's depression versus controlling

one's frustration), we found that caregivers with more of an "anger-in" style
responded significantly better to the controlling depression class, whereas care-
givers with more of an "anger out" style benefited considerably more from the
controlling frustration class (Gallagher-Thompson, Coon, & Thompson, 1996).
Such results encourage further development of models for systematic treatment
selection.
Information of this nature can be extremely valuable in assisting program
managers to allocate their limited resources to those most in need, at the same
time enabling researchers to specify a broad range of services and programs that
would be helpful to caregivers who are stressed, but perhaps not seriously dis-
tressed. We turn now to what is known currently about the particular needs and
most effective approaches with caregivers of different kinds.
ADDRESSING THE UNIQUE NEEDS OF

SUBGROUPS OF FAMILY CAREGIVERS
Men in the Caregiving Role
The National Long Term Care Survey, carried out in 1982, until recently
was the most recent survey yielding information about different demographic
groups of caregivers; it may now be considerably out of date, but it represents a
good available source of information. According to that survey, 28 % of all care-
givers are male (R. Stone et a1., 1987). Although several studies have examined
differences between male and female caregivers, there is far less research on
male caregivers specifically. The results from gender comparison studies may
be the reason that male caregiver research is not as advanced as female care-
giver research. Studies have consistently shown that men report lower levels
of negative feelings, physical symptoms, and burden relative to women (Gal-
lagher, Rose et a1., 1989; Young & Kahana, 1989).
A metanalysis of 10 studies of caregiver burden found significantly less
burden experienced by men than by women (Miller & Cafasso, 1992), but all re-
viewed studies used self-report measures of burden. The authors note that the
significant gender differences explained only 4% of the variance in caregiver
burden (Miller & Cafasso, 1992). It should also be noted that most male primary
caregivers are husbands (R. Stone et a1., 1987), so that many of the findings dis-
cussed here about male caregivers may not apply to male caregivers with other
family roles, for example, sons, nephews, sons-in-law, and so forth.
Though some have interpreted these data to indicate that intervention with
male caregivers is not as critical as intervention with female caregivers, such a
conclusion is probably premature. For example, self-reported levels of depres-
sion have been shown to increase in one study of male caregivers over a 2-year
period, while female caregivers showed no increase in depression over the
same period (Schulz & Williamson, 1991). Also, distress experienced by male
caregivers may have been underestimated or misunderstood because of the
methods or measuring instruments used to measure distress. Lutzky and Knight
(1994) point to previous findings of gender differences in recognizing and re-
porting emotional states (Notarius & Johnson, 1982; Vinick, 1984) as possible
reasons for gender differences in reported caregiver burden. However, Lutzky
and Knight (1994) found no gender differences in cardiovascular responsivity
(CVR), a physiological, nonself-report measure of stress.
Given these differences between male and female caregivers, it may be that
male caregivers have needs different from those of female caregivers in terms of
interventions to ameliorate caregiver distress. The experiences of the present
authors and anecdotal reports from other therapists who have worked with
male caregivers support this contention, but only two research papers to date
have examined a psychosocial intervention designed specifically for male care-
givers of dementia patients (Davies, Priddy, & Tinklenberg, 1986; Moseley,
Davies, & Priddy, 1988).
These two papers are an initial report and follow-up with a support group
developed for elderly male caregivers of dementia patients, and address indi-
vidual case issues as well as general themes. Davies and colleagues (1986) iden-
tified several different types of male caregivers, explaining the particular issues
they face, and Moseley and colleagues (1988) reported on the status of these
caregivers 3 years after the group started. Moseley and colleagues (1988) also
discussed several themes that were evident throughout the life of the group.
These male caregivers appeared to approach caregiving as "a challenge to be
met 'head on' " (p. 733). Their roles changed dramatically, particularly in that
they were required to carry out tasks that traditionally fit into their wives' roles.
Frustration was overtly discussed more often than sadness, and it took consid-
erably more time for men to become comfortable discussing their emotions in
the group relative to the authors' experiences with female caregivers. Finally,
the experience of caregiving was not static, but instead was constantly evolving,
and the stages of grief described by Kubler-Ross (1969) were evident throughout
the process.
The authors made several recommendations for future male caregiver
groups, including (1) offering the group as an adjunct to a larger, coeducational
information and support activity; (2) keeping the men's group small, with a lim-
ited influx of new members; (3) meeting biweekly, rather than weekly, because
of care giving schedule demands; (4) using a low to moderate level of structure;
and (5) trying to provide for an exclusively male group "whenever possible"
(Moseley et aJ., 1988, p. 135). The last recommendation is given specifically be-
cause of the authors' observations that men are underrepresented and much
more passive in mixed-gender groups. No study implementing their suggestions
for future male groups has yet been published, although one of the chapters of
the national Alzheimer's Association has published a "how-to" manual for
leaders who wish to offer men-only support groups; the manual actually con-
tains many of the same observations and suggestions (Keller, 1992).
Unfortunately, no rigorously designed experimental outcome study on the
process and results of male caregiving has been published to date, to the au-
thors' best knowledge. Because of this, and because of the limited information
currently available on how to best offer services to male caregivers, conclusions
about their needs and the types of services that will benefit them must be drawn
with caution. Further research is necessary before firm conclusions can be
reached about whether treatments that are known to work with women will
work as well with men, and whether these treatments are the best way to help
male caregivers. We also need further study on similarities and differences
between concerns and treatment needs of adult sons versus spouse caregivers,
as well as examining how men may function more often than anyone realizes in
secondary (rather than primary) caregiving roles. The impact of this on such ac-
tivities as employment and use of leisure time are two other areas that warrant
future investigation.
Ethnic and Cultural Minorities as Family Caregivers
Recently we have seen in this country both a significant increase in immi-

gration of older persons from many different countries and cultures and a defi-
nite rise in the life expectancy of racial and ethnic minority elderly, including
African Americans, Native Americans, Asian Americans and Pacific Islanders,
and persons of Hispanic origins (Jackson, 1988). There are important differ-
ences, both between and within these broad racial and ethnic designations, in
explanatory models of health and illness. These factors contribute to an extra-
ordinarily complex interaction picture that makes the study of family caregiv-
ing patterns in these groups a very challenging (and also rewarding) process.
Kleinman (1980) described eloquently how cultural customs and beliefs
about causes and treatments of disease act as strong influences on the kinds of
problems that are experienced and the kinds of interventions that are viewed as
acceptable. For example, not all cultures experience caregiving as primarily a
stressful experience; in such cultures, treatments that focus on the negative as-
pects of caregiving may not be at all well received. The reader is referred to sev-
eral studies by Haley and associates focusing on the apparent psychological
resilience and positive views about caregiving that have been found among
African American caregivers (W. Haley et a1., 1995, W. Haley et a1., 1996).
Yet on an empirical level, much less is known than should be about the
day-to-day caregiving experiences of racial and ethnic minorities as they at-
tempt to support frail elders and maintain them in the home setting. Most of the
few available empirical studies have focused on African Americans (cf. the
work of Haley and colleagues just noted, along with Dilworth-Anderson & An-
derson, 1994; Gonzalez, Gitlin, & Lyons, 1995; Hinrichsen & Ramirez, 1992, for
more specific findings). Mexican Americans are currently the fastest growing
ethnic group in this country (U.S. Bureau of the Census, 1989). Some research
has been completed that focused specifically on the needs of Hispanic families,
particularly those caring for a relative with dementia (e.g., Cox & Monk, 1993;
Sotomayor & Randolph, 1988), However, virtually no outcome studies have
been conducted with any of the major Hispanic subgroups.
Clinical reports by Henderson and Gutierrez-Mayka (1992) and Hender-
son, Gutierrez Mayka, Garcia, and Boyd (1993) describe in excellent detail how
to establish and maintain ethnically sensitive support groups for both the
Latino and African American populations of family caregivers in Florida.
These writings have encouraged others to think about how best to work with
these populations. Recent work (e.g., chapters by Gallagher-Thompson, Tala-
mantes, Ramirez, & Valverde, 1996, and Henderson, 1996) attempts to integrate
already published insights with additional clinical experience. Also, several

groups of researchers have recently been funded by the National Institute on
Aging to undertake more controlled research on the efficacy of several differ-
ent kinds of psychosocial interventions with several different groups of mi-
nority caregivers. This collaborative research program, termed the REACH
project, involves six research sites in different parts of the country. It will yield
new information about how African American and Hispanic caregivers, in par-
ticular, respond to a variety of interventions. Although no published informa-
tion is yet available from the project, basic descriptive information can be
obtained (Ory & Schulz, 1996).
The other major groups, including Asian Americans and Pacific Islanders
(e.g., Chinese, Japanese, Korean, Tongan, and Vietnamese Americans), and Na-
tive Americans, have been generally overlooked when it comes to caregiving re-
search. In the case of Asian Americans and Pacific Islanders, this may be due in
part to language issues that can make it extremely difficult to understand what
caregivers and their elders are experiencing and what their needs are. In addi-
tion, their cultural customs and values emphasize not complaining about stress
within the family, and showing great respect for elders, regardless of their frail-
ties or lack of adequate cognitive function. These values may make it very stig-
matizing to seek services and help outside the family for what is essentially
regarded as a "family affair" (see Elliott, Di Minna, Lam, & Mei, 1996; Koh &
Bell, 1987; McBride & Parreno, 1996; and Tempo & Saito, 1996, for discussion
of these issues with particular focus on Chinese, Korean, Filipino, and Japanese
American family caregivers, respectively).
Emphasizing the similarities rather than differences among them, Lockery
(1991) addressed the role of family and social support among the major racial
and ethnic groups just noted. She found several important similarities in per-
ceptions of the roles of family members, including (1) the value placed on in-
tergenerational contact, (2) the tradition ofrespect toward the elderly, and (3)
the clear family obligation for caregiving in the home, rather than in an institu-
tional setting. Lockery points out that these characteristics reflect more "tradi-
tional" values, but it is not wise to assume that traditional values are always
operative in a given family's situation. Other variables such as immigration sta-
tus, level of acculturation, degree of family contact, and socialization to the
dominant culture and its values will influence these traditions and lead to vari-
ations in family members' roles or beliefs. For example, first-generation immi-
grants are more likely to retain traditional customs or beliefs than are third- or
fourth-generation persons, who have become more acculturated to the host
country (Landrine & Klonoff, 1992).
The practice of comparing biological subgroups (such as African American
and White caregivers) on several variables is becoming more common in care-
giver research. However, because race is so interrelated with socioeconomic,
educational, and health status, we suggest that its use (as well as the use of
these other variables) to explain is limited and can lead to inaccurate conclu-
sions, which may in turn strengthen current stereotypes. For example, some
have proposed that minority caregivers experience a double jeopardy due to
disadvantages of age and race (Belgrave, Wylie, & Choi, 1993), yet the percep-
tion that race always represents a disadvantage may be shortsighted. As noted
484 Dolores Gallagher-Thompson et aI.
above, several studies have found that resilience, rather than distress, tends to
characterize African American caregivers.
Ethnicity is a concept that refers to cultural lifestyle patterns such as shared
language, customs, religion, and values (Fernando, 1991). As a multidimen-
sional construct, it is more difficult to define than race but is more likely to help
identify genuine cultural differences in caregiving that are less influenced by so-
cioeconomic status and more by one's beliefs, as related to family and tradition.
Comparisons between ethnic and Anglo caregivers have typically focused
on three variables: social support, psychological well-being or burden, and
health. Despite the belief that the social support networks of minority care-
givers differ from those of Anglos, data have been inconsistent regarding size
and frequency of contact (George, 1989; Wood & Parham, 1990). Based on their
findings, W. Haley et al. (1996) have suggested that cognitive strategies such as
positive appraisal and coping contribute to minority caregivers' abilities to
overcome the added hardships imposed by low income and poor health. Others
(Gibson, 1982; Wood & Parham, 1990) have suggested that minority caregivers'
values and beliefs, along with their life experiences, create a powerful variable
which impacts appraisal and coping, so that for many, caregiving is almost au-
tomatically less stressful than for Anglo counterparts. Thus, they may not need
or want the same kinds of services that have been developed primarily to serve
the more well-characterized needs of Anglo caregivers, who are still in the ma-
jority in this country. Clearly, future research must be culturally sensitive in the
ways it asks about caregiving, and in the types of interventions or services that
are proposed to assist minority families with the caregiving process.
A final related point concerns the underutilization of currently existing so-
cial and health care services by minority caregivers and their elders. For all the
reasons noted here, it should not come as a surprise that caregivers of varied
cultural backgrounds do not utilize extant services. For some, this has been a
matter of great concern, since their unique needs are apparently not being ad-
dressed adequately by the majority culture in its public policy and planning ef-
forts. Henderson and colleagues (1993) theorized that several factors serve to
discourage minority use of services such as support groups or clinics. These
disincentives include impersonal recruitment and maintenance strategies,
inconvenient location of services, and absence of ethnic staff representing the
target group. Recommendations include active recruitment strategies that em-
phasize individual contact via face-to-face interviews and telephone and writ-
ten follow-up, and an informal, unhurried interpersonal approach which
facilitates the development of trust between participants and staff. Additional
suggestions have been described by Arean and Gallagher-Thompson (1996).
These include active problem solving to handle practical barriers such as trans-
portation difficulties and low literacy levels; use of research funds to defray
costs associated with participating in a project over time, such as "sitting" costs
for someone to stay with a demented spouse or parent while the caregiver re-
ceives services; and staff flexibility around scheduling, so that missed appoint-
ments can be made up with a minimum of embarrassment and explanations.
These and other recommendations in this section, such as the employment of
bilingual and, whenever possible, appropriately bicultural, staff, may seem
costly and time-consuming to implement. However, research and practice will
continue to lag significantly behind caregivers' needs until such strategies are
broadly implemented.
SUMMARY AND FUTURE DIRECTIONS
Research on caregiving and clinical interventions designed to help care-

givers have gone through several transformations, as we have reviewed. The
field started with a general awareness that caregiving is a stressful responsibil-
ity. Research questions in that phase focused on assessing the level of stress and
examining the impact of stress on physical and emotional well-being of the
caregiver. Other early research examined the behaviors of the demented care re-
ceiver as sources of stress. Interventions emphasized support groups, in which
caregivers could share information and offer emotional support to each other.
Out of this early work, questions of greater sophistication developed. Care-
giving came to be understood as a complex process that could not adequately be
captured by notions of level of stress or distress. Instead, researchers began to
examine both the rewards and the problems associated with caregiving, and to
see how these interacted to create complex emotional and behavioral responses
in the caregiving context. Researchers also began to explore caregiving as a lon-
gitudinal process, which may be experienced very differently at different
points. In this phase, interventions began to shift from simple support groups to
more complex psychoeducational models. In both group interventions and in-
dividual counseling, an emphasis on understanding and support were main-
tained, but additional factors were emphasized, such as learning to handle one's
own emotional reactions to caregiving, developing skills for maintaining one's
own well-being as a caregiver, and developing better problem-solving skills.
Research at the second level produced more information, which led to yet
a third phase of caregiver research and intervention. In this latest phase, indi-
vidual variability in the caregiving experience is being studied even more
broadly, with greater sensitivity to racial, ethnic, and other cultural features, as
well as to the role of gender of the caregiver: Caregiving is being viewed more in
terms of the ongoing, complex relationships between the patient, the caregiver,
the broader family or kinship network, and the cultural norms and expectations
of a community. In this phase, intervention is being viewed more broadly as
well, with sensitivity to how caregiving is defined among different ethnic and
cultural groups, and by male as well as female caregivers, and with special at-
tention to factors that influence what skills might be seen as most important for
caregivers from different backgrounds.
We applaud these developments in our understanding of the caregiving
process and experience. Caregiving for a demented family member can be easy
to define at one level, but the complexity and depth of the situation become
compelling as research progresses and as our efforts to intervene mature. It
would have been hard to predict future directions for research and clinical ac-
tivity in the beginning, and we should continue to be guided by each wave of
research rather than by a pre-set agenda. However, some general ideas about fu-
ture directions can be suggested.
First, the emphasis on ethnic factors in caregiving needs to continue. To

date, only African American and Hispanic caregivers have any appreciable
body of research or ongoing initiatives. And each of these groups is complex
and multifaceted; rather than pursuing "African American" caregiving, for
example, it may be important to recognize issues for subgroups of that general
category (e.g., in different parts ofthe country, caregivers of different socioeco-
nomic status, in matriarchal family structures versus two-parent family struc-
tures, for male African American caregivers). At each step, refinements in
interventions should keep step with basic research.
At the same time, there is a need to seek underlying principles while ex-
amining complexity and diversity. Accumulating facts about different sub-
groups is an extremely helpful and positive step for many reasons, but part of
its value is that it challenges simplistic and culturally biased assumptions about
the meaning and experience of caregiving. When basic assumptions are chal-
lenged, it becomes possible to search for unifying themes in a more open, less
culture-biased way. For example, most caregiver research has started with the
assumption that it is important to keep demented patients at home as long as
possible, but with a parallel assumption that institutional placement may be
necessary and appropriate at certain phases of dementing illness or in certain
family situations. One focus of research then becomes the caregiver experiences
that might lead to institutional placement of the care receiver. Home caregiving
is a widely shared value, but it must be recognized that it is a value and that it
flows from particular assumptions about the "best" environment for a de-
mented person, the meaning of "home and family," and so forth. Future re-
search might look at how caregivers try to maintain "optimal" conditions
within their own framework, rather than assuming that all caregivers and fam-
ilies share a common perspective or, conversely, simply listing the different
strategies observed across different cultural groups.
Finally, the future of caregiving research and intervention will undoubt-
edly be heavily influenced by the politics of health care provision and financial
support for older adults. Caregivers are being expected to carry a heavier and
heavier burden as other programs and health care benefits are targeted for cuts
in funding. Families receiving all their care in managed care systems, for exam-
ple, may have very different caregiving experiences from those receiving care in
fee-for-service systems. Researchers in this area, as in all areas of health care,
must recognize that the pace of change in the next decade will be rapid, and
they must stay closely informed about health care policy and take steps as nec-
essary to advocate for caregiving support programs and research funding.
REFERENCES
Altholz,]. A. S. (1991). Caregiving: The emotional rewards and challenges. In C. Nelson-Morrill

(Ed.) The Florida caregiver's handbook (pp. 7-22). Tallahassee. FL: Healthtrac Books.
American Psychiatric Association. (1980). Diagnostic and statistical manual o/mental disorders
(3rd ed.). Washington, DC: Author.
Anthony-Bergstone. C., Zarit. S. H., & Gatz. M. (1988). Symptoms of psychological distress among
caregivers of dementia patients. Psychology and Aging, 3. 245-248.
Arean, p, & Gallagher-Thompson, D. (1996). Issues and recommendations for the recruitment and
retention of older minorities into clinical research. Journal of Consulting and Clinical Psy-
chology, 64, 875-880.
Arling, G., & McAuley, W. (1983). The feasibility of public payments for family caregivers. Geron-
tologist, 23, 300-306.
Barusch, A. (1988). Problems and coping strategies of elderly spouse caregivers. Gerontologist, 28,
677-685.
Baumgarten, M., Battista, R N., Infante-Rivard, C., Hanley, J. A .. , Becker, R, & Gauthier, S. (1992).
The psychological and physical health of family members caring for an elderly person with
dementia. Journal of Clinical Epidemiology, 45, 61-70.
Beck, A. T., Rush, J., Shaw, B., & Emery, G. (1979). Cognitive therapy of depression. New York: Guilford.
Belgrave, 1. L., Wykle, M. 1., & Choi, T. M. (1993). Health, double jeopardy and culture: The use of
institutionalization by African Americans. Gerontologist, 33, 379-385.
Blazer, D. G. (1990). The epidemiology of psychiatric disorders in late life. In E. W. Busse & D. G.
Blazer (Eds.), Geriatric psychiatry (pp. 235-260). Washington, DC: American Psychiatric Press.
Blazer, D. G. (1994). Geriatric psychiatry. In R E. Hales. S. C. Yodfsky, & J. A. Talbott (Eds.), The
American Psychiatric Press textbook of psychiatry (2nd ed., pp. 1405-1421). Washington, DC:
Blazer, D. G., Hughes, D. c., & George, 1. K. (1987). The epidemiology of depression in an elderly
community population. Gerontologist, 27, 281-287.
Bourgeois, M. S., Schulz, R, & Burgio, 1. (1996). Intervention for caregivers of patients with
Alzheimer's disease: A review and analysis of content, process, and outcomes. International
Journal of Human Development, 43, 35-92.
Brody, E. M. (1990). Women in the middle: Their parent-care years. New York: Springer.
Brody, E. M., Litvin, S. T., Hoffman, C., & Kleban, M. H. (1995). Marital status of caregiving daugh-
ters and co-residence with dependent parents. Gerontologist, 35, 75-85.
Cantor, M. H. (1983). Strain among caregivers: A study of experience in the United States. Geron-
tologist, 23, 597-604.
Cicirelli, V. G. (1983). A comparison of helping behavior to elderly parents of adult children with
intact and disrupted marriages. Gerontologist, 23, 619-625.
Clipp, E. C., & George, 1. K. (1990). Caregiver needs and patterns of social support. Journal of Geron-
tology: Social Sciences, 45, S102-S111.
Coppel, D. B., Burton, C., Becker, T., & Fiore, J. (1985). Relationships of cognitions associated with
coping reactions to depression in spousal caregivers of Alzheimer's disease patients. Cognitive
Therapy and Research, 9, 253-266.
Cox, C., & Monk, A. (1993). Hispanic culture and family care of Alzheimer's patients. Health and
Social Work, 18(2),92-100.
Cutler. S. J., & Coward, R T. (1992). Availability of personal transportation in households of elders:
Age, gender, and residence differences. Gerontologist. 32, 77-81.
Davies, H., Priddy, T. M., & Tinklenberg, J. R (1986). Support groups for male caregivers of
Alzheimer's patients. Clinical Gerontologist, 5(3/4), 384-395.
Dean, A., Kolody, B., & Wood, P. (1990). Effects of social support from various sources on depres-
sion and elderly person. Journal of Health and Social Behavior, 2, 148-161.
Deimling, G. T., & Bass, D. M. (1986). Symptoms of mental impairment among older adults and their
effects on family caregivers. Journal of Gerontology, 41, 778-784.
Dick, 1. P., & Gallagher-Thompson, D. (1995). Cognitive therapy with the core beliefs of a distressed
lonely caregiver. Journal of Cognitive Psychotherapy: An International Quarterly, 9, 215-227.
Dilworth-Anderson, P., & Anderson, N.B. (1994). Dementia caregiving in blacks: A contextual ap-
proach to research. In B. Lebowitz, E. Light, & G. Neiderehe (Eds.), Mental and physical health
of Alzheimer caregivers (pp. 385-409), New York: Springer.
Draper, B. M., Poulos, C. T., Cole, A. D., Poulos, R G., & Ehrlich, F. (1992). A comparison of care-
givers for elderly stroke and dementia victims. Journal of the American Geriatrics Society, 35,
896-901.
Drinka, T. T., Smith, T., & Drinka, P. T. (1987). Correlates of depression and burden for informal care-
givers of patients in a geriatrics referral clinic. Journal of the American Geriatrics Society, 35,
522-525.
Dura, J. R., Stukenberg, K. W., & Kiecolt-Glaser, J. K. (1990). Chronic stress and depressive disorders
in older adults. Journal of Abnormal Psychology, 99, 284-290.
Dura, J. R.• Stukenberg, K. W., & Kiecolt-Glaser, J. K. (1991). Anxiety and depressive disorders in
adult children caring for demented parents. Psychology and Aging, 6,467-473.
Elliott, K. S., Di Minno, M., Lam, D., & Mei, A. (1996). Working with Chinese families in the context
of dementia. In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp.
89-102). Washington, DC: Taylor & Francis.
Evans, M. E.• Copeland. J. R. M., & Dewey, M. E. (1991). Depression in the elderly in the community:
Effect of physical illness and selected social factors. International Journal of Geriatric Psychi-
atry, 6, 787-795.
Fengler, A. P., & Goodrich, N. (1979). Wives of elderly disabled men: The hidden patients. Geron-
tologist, 19, 175-183.
Fernando, S. (1991). Mental health, race and culture. Hampshire. England: Macmillan Education.
Fiore, J., Coppel, D. B., Becker, J., & Cox, G. B. (1986). Social support as a multifaceted construct: Ex-
amination of important dimensions for adjustment. American Journal of Community Psy-
chology. 14, 93-111.
Futterman, A., Thompson, L., Gallagher-Thompson, D., & Fertis, R. (1995). Depression in later life:
Epidemiology, assessment, etiology, and treatment In E. E. Beckham & W. R. Leber (Eds.),
Handbook of depression (2nd ed., pp. 494-525). New York: Guilford.
Gallagher, D., Rose, J., Rivera, P., Lovett, S., & Thompson, L. W. (1989). Prevalence of depression in
family caregivers. Gerontologist, 29, 449-456.
Gallagher, D., Wrabetz, A., Lovett, S., DelMaestro, S., & Rose, J. (1989). Depression and other nega-
tive affects in family caregivers. In E. Light & B. Liebowitz (Eds.). Alzheimer's disease treat-
ment and family stress: Directions for research (pp. 218-244). Washington. DC: National
Institute of Mental Health.
Gallagher-Thompson, D. (1994a). Clinical intervention strategies for distressed caregivers: Rationale
and development of psychoeducational approaches. In E. Light, G. Niederehe, & B. D.
Lebowitz (Eds.), Stress effects on family caregivers of Alzheimer's patients: Research and in-
terventions (pp. 260-277). New York: Springer.
Gallagher-Thompson, D. (1994b). Direct services and interventions for caregivers: A review of ex-
tant programs and a look to the future. In M. H. Cantor (Ed.), Family caregiving: Agenda for the
future (pp. 102-122). San Francisco: American Society on Aging.
Gallagher-Thompson, D.. & DeVries. H. (1994). "Coping with Frustration" classes: Development and
preliminary outcomes with women who care for relatives with dementia. Gerontologist, 34,
548-552.
Gallagher-Thompson, D., Coon, D., & Thompson, L. W. (1996, November). Anger expression by type
of treatment interaction predicts treatment outcomes in family caregivers. Presented at the
Gerontological Society of America 49th Annual Scientific Meeting, Washington, DC.
Gallagher-Thompson. D.• & Steffen, A. (1994). Comparative effectiveness of cognitive/behavioral
and brief psychodynamic psychotherapies for the treatment of depression in family care-
givers. Journal of Consulting and Clinical Psychology, 62, 543-549.
Gallagher-Thompson, D., Talamantes, M.• Ramirez. R., & Valverde, I. (1996). Service delivery issues
and recommendations for working with Mexican American family caregivers. In G. Yeo & D.
Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp. 137-152). Washington, DC: Tay-
lor & Francis.
Genevay, B. (1994). Family issueslfamily dynamics: A caregiving odyssey to 2001 and beyond. In
M. H. Cantor (Ed.), Family caregiving: Agenda for the future (pp. 89-101). San Francisco:
American Society on Aging.
George, L. K. (1989). Social and economic factors. In E. W. Busse & D. G. Blazer (Eds.). and Aging,
5,277-283.
George, L. K. (1983). Caregiver well-being. Correlates and relationships with participation in com-
munity self-help groups (Final report to the AARP Andrers Foundation). Durham, NC: Duke
University Medical Center.
George, L. K., & Gwyther, L. P. (1984, November). The dynamics of caregiver burden: Changes in
caregiver well-being over time. Paper presented at the Annual Scientific Meeting of the Geron-
tological Society of America, San Antonio. TX.
George, L. K.. & Gwyther. L. P. (1986). Caregiver well-being: A multidimensional examination of
family caregivers of demented adults. Gerontologist, 26, 253-259.
Gibson, R. C. (1982). Blacks in middle and late life: Resources and coping. Annals of the American
Academy of Political and Social Science, 464, 79-90.
Gonyea, J. G. (1989). Alzheimer's disease support groups: An analysis of their structure, format and
perceived benefits. Social Work in Health Care, 14,61-72.
Gonzalez, E., Gitlin, L., & Lyons, K. J. (1995). Review of the literature on African American care-
givers of individuals with dementia. Journal of Cultural Diversity. 2 (2), 40-48.
Gore, S. (1981). Stress-buffering functions of social supports: An appraisal and clarification of re-
search methods. In B. Dohrenwend & B. P. Dohrenwend (Eds.), Stressful life events and their
contexts (pp. 202-222). New York: Neale Watson Academic.
Greene, V. 1., & Monahan, D. J. (1987). The effect of professionally guided caregiver support and ed-
ucation groups on institutionalized care receivers. Gerontologist, 27, 716-721.
Greene, V. L., & Monahan, D. J. (1989). The effect of a support and education program on stress and
burden among family caregivers to frail elderly persons. Gerontologist, 29, 472-480.
Gwyther, 1. P. (1990). Letting go: Separation-individuation in a wife of an Alzheimer's patient.
Haley, W. E., West, C. A. C, Wadley, V. G., Ford, G. R., White, F. A., Barrett, J. J., Harrell, 1. E., & Roth,
D. 1. (1995). Psychological, social, and health impact of caregiving: A comparison of Black
and White dementia family caregivers and noncaregivers. Psychology and Aging, 10, 540-552.
Haley, W., Roth, D. 1., Coleton, M., Ford, G. R., West, C. A. C., Collins, R. P., & Isobe, T. (1996). Ap-
praisal, coping, and social support as mediators of well-being in Black and White family care-
givers of patients with Alzheimer's disease. Journal of Consulting and Clinical Psychology. 64,
121-129.
Haley, W. E. (1989). Group intervention for dementia family caregivers: A longitudinal perspective.
Gerontologist, 29,481-483.
Haley, W. E., Levine, E. G., Brown, S. L., & Bartolucci, A. A. (1987). Stress, appraisal, coping and so-
cial support as predictors of adaptational outcome among dementia caregivers. Psychology
and Aging, 2, 323-330.
Haley, W. E., Levine, E. G., Brown, S. 1., Berry, J. W., & Hughes, G. H. (1987). Psychological, social
and health consequences of caring for a relative with senile dementia. Journal of the Ameri-
can Geriatrics Society, 35, 405-411.
Henderson, J. N. (1996). Cultural dynamics of dementia in a Cuban and Puerto Rican population in
the United States. In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp.
153-166). Washington, DC: Taylor & Francis.
Henderson, J. N., & Gutierrez-Mayka, M. (1992). Ethnocultural themes in caregiving to Alzheimer's
disease patients in Hispanic families. Clinical Gerontologist, 11 (3/4),59-74.
Henderson, J. N., Gutierrez-Mayka, M., Garcia, J., & Boyd, S. (1993). A model for Alzheimer's dis-
ease support group development in African-American and Hispanic populations. Gerontolo-
gist, 33, 409-414.
Hinrichsen, G. A., & Ramirez, M. (1992). Black and White dementia caregivers: A comparison of
their adaptation, adjustment and service utilization. Gerontologist, 32, 375-381.
Hooker, K., Frazier, 1. D., & Monahan, D. J. (1994). Personality and coping among caregivers of
spouses with dementia. Gerontologist, 34, 386-392.
Horowitz, A. (1985). Family caregiving to the frail elderly. In M. P. Lawton & C. Maddox (Eds.), An-
nual review of gerontology and geriatrics (Vol. 5, pp. 194-246). New York: Springer.
Jackson, J. S. (1988). Growing old in black America: Research on aging black populations. In J. S.
Jackson (Ed.). The black American elderly: Research on physical and psychosocial health (pp.
Kaplan, C. P., & Gallagher-Thompson, D. (1995). Treatment of clinical depression in caregivers of
spouses with dementia. Journal of Cognitive Psychotherapy: An International Quarterly. 9,
35-44.
Keller, J. L. (1992). Male caregivers' guidebook: Caring for your loved one with Alzheimer's at home.
Des Moines, IA: Alzheimer's Association Des Moines Chapter.
Kiecolt-Glaser, J. K., Glaser, R., Shuttleworth, E. E., Dyer, C. S., Ogrocki, P., & Speicher, C. E. (1987).
Chronic stress and immunity in family caregivers of Alzheimer's disease patients. Psychoso-
matic Medicine, 49, 523-535.
Kiecolt-Glaser, J. K., Dura, J. R., Speicher, C. E., Trask, J., & Glaser, R. (1991). Spousal caregivers of
dementia victims: Longitudinal changes in immunity and health. Psychosomatic Medicine,
53, 345-362.
Kleinman. A. (1980). Patients and healers in the context of culture. Berkeley: University of Califor-
nia Press.
Knight. B. G.• Lutzky. S. M.• & Macofsky-Urban. F. (1993). A meta-analytic review of interventions
for caregiver distress: Recommendations for future research. Gerontologist, 33, 240-248.
Koenig. H. G.• & Blazer. D. G. (1992). Epidemiology of geriatric affective disorders. Clinics in Geri-
atric Medicine, 8. 235-251.
Koh. J. Y., & Bell. W. G. (1987). Korean elders in the United States: Intergenerational relations and
living arrangements. Gerontologist, 27, 66-71.
Kubler-Ross. E. (1969). On death and dying. New York: Macmillan.
Landrine. H.• & Klonoff. E. A. (1992). Culture and health-related schemes: A review and proposal
for interdisciplinary integration. Health Psychology, 11. 267-276.
Lawton. M. P.• Moss. M.• Kleban. M. H.. Glicksman. A.• & Rovine. M. (1991). A two-factor model of
caregiving appraisal and psychological well-being. Journal of Gerontology: Psychological Sci-
ences. 46, P181-P189.
Lieberman. M. A.• & Fisher. L. (1995). The impact of chronic illness of the health and well-being of
family members. Gerontologist. 35. 94-102.
Lockery. S. A. (1991). Family and social supports: Caregiving among racial and ethnic minority el-
ders. Generations. FalllWinter. 58-62.
Lovett. S.• & Gallagher. D. (1988). Psychoeducational interventions for family caregivers: Prelimi-
nary efficacy data. Behavior Therapy. 19.321-330.
Lutzky. S. M., & Knight. B. G. (1994). Explaining gender differences in caregiver distress: The roles
of emotional attentiveness and coping styles. Psychology and Aging. 9(4).513-519.
MaloneBeach. E., & Zarit. S. (1995). Dimensions of social support and social conflict as predictors
of caregiver depression. International Psychogeriatrics. 7, 25-38.
McBride. M.• & Parreno, H. (1996). Filipino American families and caregiving. In G. Yeo & D. Gal-
lagher-Thompson (Eds.). Ethnicity and the dementias (pp. 123-135). Washington. DC: Taylor
& Francis.
Miller. B. (1987). Gender and control among spouses of the cognitively impaired: A research note.
Gerontologist. 27, 447-453.
Miller. B.• & Cafasso. L. (1992). Gender differences in caregiving: Fact or artifact. Gerontologist, 32,
498-507.
Mirowsky. J.• & Ross. C. E. (1990). Age and depression. Journal of Health and Social Behavior, 33,
187-205.
Mittelman, M.. Ferris. S.. Shulman, E., Steinberg. G.. Mackell. J.. & Ambinder, A. (1994). Efficacy
of multicomponent individualized treatment to improve the well-being of Alzheimer's care-
givers. In E. Light. G. Niederche. & B. D. Lebowitz (Eds.). Stress effects on family caregivers of
Alzheimer's patients: Research and interventions (pp. 156-184). New York: Springer.
Mohide. E. A., Pringle. D. M.. Streiner. D. L.• Gilbert. J. R.. Muir. G.• & Tew. M. (1990). A randomized
trial of family caregiver support in the home management of dementia. Journal of the Ameri-
can Geriatrics Society. 38, 446-454.
Moseley, P. W.• Davies. H. D.• & Priddy. J. M. (1988). Support groups for male caregivers of
Alzheimer's patients: A follow-up. Clinical Gerontologist, 7. 127-136.
Mullan. J. T. (1992). The bereaved caregiver: A prospective study of changes in well-being. Geron-
tologist, 32. 673-683.
National Center for Health Statistics. (1987). Health statistics on older persons. United States. 1986.
Vital and health statistics (Series 3. No. 25. DHHS Publication No. PHS 87-1409). Washington.
DC: U.S. Government Printing Office.
Norris. F.• & Murrell. S. (1987). Transitory impact of life-event stress on psychological symptoms in
older adults. Journal of Health and Social Behavior, 28,197-211.
Norris. F.• & Murrell, S. (1990). Social support. life events. and stress as modifiers of adjustment to
bereavement by older adults. Psychology and Aging, 5,429-436.
Notarius. C. I.. & Johnson, J. S. (1982). Emotional expression in husbands and wives. Journal of Mar-
riage and the Family. 44, 483-489.
Ory. M.• & Schulz. R. (1996. November). Resources for enhancing Alzheimer's caregiver health
(REACH). Innovative approaches to AD Caregiving Interventions. Paper presented at the an-
nual meeting of the Gerontological Society of America. Washington. DC.
Oxman, T., Freeman, D., Manheimer, E., & Stukel, T. (1994). Social support and depression after car-
diac surgery in elderly patients. American Journal of Geriatric Psychiatry. 2. 309-323.
Pearlin, 1. L (1992). The careers of caregivers. Gerontologist. 32, 647.
Pearlin, L. L, Mullan, J. T., Semple, S. J., & Skaff, M. M. (1990). Caregiving and the stress process:
An overview of concepts and their measures. Gerontologist, 3D, 583-595.
Pinkston, E. M., & Linsk, N. 1. (1984). Behavioral family intervention with the impaired elderly.
Pinkston, E. M., Linsk, N. L, Young, R. N. (1988). Home based behavioral family treatment ofthe im-
paired elderly. Behavior Therapy, 19, 331-344.
Pruchno, R. A., & Resch, N. L. (1989). Aberrant behaviors and Alzheimer's disease: Mental health
effects on spouse caregivers. Journals of Gerontology: Social Sciences, 44, Sl77-S182.
Pruchno, R. A., Kleban, J. E., Michaels, N. P., & Dempsey, N. P. (1990). Mental and physical health
of caregiving spouses: Development of a causal model. Journals of Gerontology: Psychological
Sciences, 45 ,P192-P199.
Quayhagen, M. P., & Quayhagen, M. (1989). Differential effects of family-based strategies on
Alzheimer's disease. Gerontologist, 29, 150-155.
Radloff, 1. S. (1977). The CES-D scale: A self-report depression scale for research in the general pop-
ulation. Applied Psychological Measurement, 1,382-401.
Redinbaugh, E. M., MacCallum, R. C., & Kiecolt-Glaser, J. K. (1995). Recurrent syndromal depres-
sion in caregivers. Psychology and Aging, 10, 358-368.
Riskind, J. H., Beck, A. T., Berchick, R. J., Brown, G., & Steer, R. A. (1987). Reliability of DSM-II di-
agnoses for major depression and generalized anxiety disorder using the structured clinical in-
terview for DSM-IL Archives of General Psychiatry. 44, 817-820.
Rivera, P. A., Rose, J., Futterman, A., Lovett, S., & Gallagher-Thompson, D. (1991). Dimensions of
perceived social support in clinically depressed and nondepressed female caregivers. Psy-
Robins, 1. N., Helzer, J. E., Croughan, J., & Ratcliff, K. S. (1981). National Institute of Mental Health
Diagnostic Interview Schedule: Its history, characteristics and validity. Archives of General
Robinson, K. M. (1989). Predictors of depression among wife caregivers. Nursing Research, 38,
359-363.
Rose, J., & DelMaestro, S. (1990). Separation-individuation conflict as a model for understanding
distressed caregivers: Psychodynamic and cognitive case studies. Gerontologist, 3D, 693-697.
Russell, D. W., & Cutrona, C. E. (1991). Social support, stress, and depressive symptoms among the
elderly: Test of a process model. Psychology and Aging, 6, 190-201.
Russo, J., Vitaliano, P. P., Brewer, D., Katon, W., & Becker, J. (1995). Psychiatric disorders in spouse
caregivers of care-recipients with Alzheimer's disease and matched controls: A diathesis-
stress model of psychopathology. Journal of Abnormal Psychology. 194, 197-204.
Schorr, A. (1980). "Thy father and thy mother": A second look at filial responsibility and family pol-
icy (SSA Publication No. 13-11953). Washington, DC: U.S. Department of Health and Human
Services.
Schulz, R., & Williamson, G. M. (1991). A 2-year longitudinal study of depression among
Alzheimer's caregivers. Psychology and Aging, 6. 569-578.
Schulz, R., Tompkins, C. A., Wood, D., & Decker, S. (1987). The social psychology of caregiving:
Physical and psychological costs to providing support to the disabled. Journal of Applied So-
cial Psychology. 17, 401-428.
Schulz, R., Tompkins, C. A., & Rau, M. T. (1988). A longitudinal study of the psychosocial impact
of stroke on primary support persons. Psychology and Aging, 3, 131-141.
Schulz, R., Visintainer, P., & Williamson, G. M. (1990). Psychiatric and physical morbidity effects of
caregiving. Journals of Gerontology: Psychological Sciences, 45, P181-P191.
Schulz, R., O'Brien, A. T., Bookwala, J., & Fleissner, K. (1995). Psychiatric and physical morbidity
effects of dementia caregiving: Prevalence, correlates, and causes. Gerontologist, 35, 771-791.
Shields, C. G. (1992). Family interaction and caregivers of Alzheimer's disease patients: Correlates
of depression. Family Process, 31, 19-33.
Snow, R. E. (1991). Aptitude-treatment interaction as a framework for research on individual dif-
ferences in psychotherapy. Journal of Consulting and Clinical Psychology. 59, 205-216.
Sotomayor, M., & Randolph, S. (1988). A preliminary review of caregiving issues and the Hispanic
family. In M. Sotomayor & H. Curiel (Eds.), Hispanic elderly: A cultural signature (pp.
137-160). Edinburg, TX: Pan American University Press.
Spitzer, R., & Endicott, J. (1978). Research diagnostic criteria: Rationale and reliability. Archives of
General Psychiatry, 35, 773-782.
Spitzer, R. L., Williams, J. B., Endicott, J., & Gibbon, M. (1987). Structured clinical interview for
DSM-II-R disorders-Nonpatient version (SCID-NPJ. New York: New York State Psychiatric In-
stitute, Biometrics Research Department.
Spitzer, R. L., Williams, J. B., Gibbon, M., & Furst, M. B. (1992). The structured clinical interview for
DSM-III-R (SCID). I: History, rationale, and description. Archives of General Psychiatry, 49,
624-629.
Steffen, A. M., Gallagher-Thompson, D., Zeiss, A. M., & Willis-Shore, J. (1994, August). Self-efficacy
for caregiving: Psychoeducational interventions with dementia family caregivers. Paper pre-
sented at the American Psychological Association, Los Angeles.
Stone, R., Cafferata, G. L., & Sangl, J. (1987). Caregivers of the frail elderly: A national profile. Geron-
tologist, 27, 616-626.
Tempo, P., & Saito, A. (1996). Techniques of working with Japanese American families. In G. Yeo &
D. Gallagher-Thompson (Eds.), Ethnicity and the dementias (pp. 109-122). Washington, DC:
Taylor & Francis.
Teri, 1., & Gallagher, D. G. (1991). Cognitive-behavioral interventions for treatment of depression
in Alzheimer's patients. Gerontologist, 21, 413-416.
Teri, L., & Logsdon, R. (1991). Identifying pleasant activities for individuals with Alzheimer's dis-
ease: The Pleasant Events Schedule-AD. Gerontologist, 21, 124-127.
Teri, L., & Uomoto, J. (1991). Reducing excess disability in dementia patients: '!raining caregivers to
manage patient depression. Clinical Gerontologist, 49-63.
Thompson, E., Futterman, A., Gallagher-Thompson, D., Rose, J., & Lovett, S. (1993). Social support
and caregiving burden in family caregivers of frail elders. Journal of Gerontology: Social Sci-
ences, 48,S245-S254.
Toseland, R. W., & Rossiter, C. M. (1989). Group interventions to support family caregivers: A re-
view and analysis. Gerontologist, 29, 438-448.
Toseland, R. W., & Smith, G. C. (1990). Effectiveness of individual counseling by professional and
peer helpers for family caregivers of the elderly. Psychology and Aging, 5, 256-263.
Toseland, R. W., Rossiter, C. M., & Labrecque, M. D. (1989). The effectiveness of peer-led and pro-
fessionally led groups to support family caregivers. Gerontologist, 29, 465-471.
U.S. Bureau of the Census. (1989). "Projections of the populations of the United States, by age, sex,
and race: 1988 to 2080," by Gregory Spencer. Current Population Reports Series P-25, No.
1018.
U.S. Department of Labor, Bureau of Labor Statistics. (1990). Employment and earning, 37 (1).
Washington, DC: U.S. Government Printing Office.
U.S. House of Representatives Select Committee on Aging. (1987). Exploding the myth: Caregiving
in America (Committee Publication No. 99-1611). Washington, DC: U.S. Government Print-
ing Office.
U.S. Senate Special Committee on Aging, the American Association of Retired Persons, the Fed-
eral Council on the Aging, and the U.S. Administration on Aging. (1991). Aging America:
Trends and projections. (Publication No. (FCoA) 91-28001). Washington, DC: U.S. Department
of Health and Human Services. Washington, DC.
Vinick, B. H. (1984). Elderly men as caretakers of wives. Journal of Geriatric Psychiatry, 17, 61-68.
Vitaliano, P. P., Russo, J., Young, H. M., Teri, L., & Maiuro, R. D. (1991). Predictors of burden in
spouse caregivers of individuals with Alzheimer's disease. Psychology and Aging, 6"
392-402.
Whitlatch, C. J., Zarit, S. H., & von Eye, A. (1991). Efficacy of interventions with caregivers: A re-
analysis. Gerontologist, 31, 9-14.
Williamson, G. M., & Schulz, R. (1992). Physical illness and symptoms of depression among elderly
outpatients. Psychology and Aging, 7,343-351.
Wood, J. B., & Parham, F. A. (1990). Coping with perceived burden: Ethnic and cultural issues in
Alzheimer family caregiving. Journal of Applied Gerontology, 9, 325-339.
Wright, 1., Clipp, E., & George, 1. (1993). Health consequences of caregiver stress. Medicine, Exer-
cise, Nutrition, and Health, 2, 181-195.
Young, R. F., & Kahana, E. (1989). Specifying caregiver outcomes: Gender and relationship aspects
of caregiver strain. Gerontologist, 29, 660-666.
Zarit, S. H. (1990). Interventions with frail elders and their families: Are they effective and shy? In
M. A. P. Stephens, J. H. Crowther, S. E. Hobfoll, & D. L. Tennebaum (Eds.l. Stress and coping
in later life families (pp. 241-265). Washington, DC: Hemisphere.
Zarit, S. H., & Whitlatch, C. J. (1992). Institutional placement: Phases of the transition. Gerontolo-
gist, 32, 665-672.
Zarit, S. H., Anthony, C. R., & Boutselis. M. (1987). Interventions with caregivers of dementia pa-
tients: Comparison of two approaches. Psychology and Aging, 2. 225-232.
Zarit, S. H., Birkel, R. C., & MaloneBeach, E. (1989). Spouses as caregivers: Stresses and interven-
tions. In M. Z. Goldstein (Ed.). Family involvement in the treatment of the frail elderly. Wash-
ington, DC: American Psychiatric Association.
Zeiss, A., & Lewinsohn, P. (1986). Adapting behavioral treatment for depression to meet the needs
of the elderly. Clinical Psychologist, 39, 98-100.
CHAPTER 22
Prevention
PETER V. RABINS
INTRODUCTION AND DEFINITIONS
Prevention is the ultimate goal of the health professional. However, prevention

in the mental health field has had a checkered career. Broad promises have not
been backed up with results and prospective trials have been few and far be-
tween (Wilson, Simpson, & McCaughey, 1983).
Prevention
Prevention is defined as the avoidance or diminution of ill health and its

sequelae. Three levels of prevention have been defined. Primary prevention is
the total avoidance of a condition. Childhood vaccination and water fluorida-
tion are two examples of successful primary prevention. Secondary prevention
is defined as the prompt recognition of a disorder and initiation of appropriate
treatment. Here the goal is to minimize acute morbidity and eliminate its se-
quelae. The identification and treatment of individuals who have had sexual
contact with a person with syphilis is an example. Tertiary prevention is the
provision of maximal treatment that minimizes the long-term sequelae of
chronic illness. Tertiary prevention is appropriate for conditions such as per-
sonality disorder, schizophrenia, manic depression, and dementia.
A task force of the Institute of Medicine (10M) (Mrazek & Haggerty, 1994)
has suggested a modification of this categorization for the mental health fields.
The three stages it identified are treatment, management, and maintenance.
Both sets of definitions have inherent difficulties. For example, it is often
not clear whether an action is secondary or tertiary prevention. On the other
hand, the 10M categorization does not recognize that complete avoidance is the
ultimate goal of prevention.
PETERV. RASINS • Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
School of Medicine, Baltimore, Maryland 21287-7279,
495
496 Peter V. Rabins
The interest in the prevention of emotional disorder is not new. For exam-
ple, eminent American psychiatrist Adolf Meyer (1915) stated the following:
"Where, then, shall we attack the problem of prevention? By reinforcing the ex-
isting helps, the hospitals, the dispensaries, the special agencies; by adapting
the schools to the needs of the pupils; by facing pointedly the problems of al-
coholism and syphilis; but above all, by starting a quiet work of community-
organization, building up manageable district units, and by inspiring a con-
structive atmosphere among people who can know and understand people each
other and who have common needs" (p. 557). Meyer also suggested that efforts
be made to counsel families of persons with major mental illness and cautioned
against raising hopes unrealistically. These suggestions remain appropriate 80
years later.
Risk Factors
One important approach to developing prevention strategies is the identi-

fication of risk factors. Three measurements have been developed to convey the
degree of risk. Both the odds ratio and the relative risk measure the strength of
the relationship between single risk factors and a disorder or disease. Each is
defined as the ratio of incident (new) cases in persons with the risk factor to the
number of cases in persons without the risk factor. The two measures differ in
the sources of data used to calculate them. The odds ratio is based on data from
cohort or case control studies, whereas relative risks are calculated on data from
population-based samples. The third measure, attributable risk, refers to the
percentage of cases of a disorder caused by a specific risk factor. It differs from
the odds ratio and relative risk because its value depends on the prevalence
(frequency) of the risk factor in the population.
Clinical Logics
A final set of definitions important to prevention are two models of clinical

logic. Categorical or dichotomous logic is used when a condition is either pres-
ent or absent. Examples from medicine are a broken bone or a heart attack.
Schizophrenia, bipolar disorder, and dementia are mental health examples.
This approach dates back to the 17th-century writings of the British physician
Sydenham, who suggested that clusters of signs and symptoms can be found
among many patients and that these clusters are similar across cultures and
eras. This approach is sometimes referred to as the disease or "medical" model
because it assumes an underlying biological abnormality.
A second type of clinical logic is labeled continuous or dimensional. It is
used for human characteristics that are universal and distributed in the popu-
lation in a Gaussian (so-called bell curve or normal) fashion. Personality, grief,
and reaction to stress are examples of characteristics for which this logic is
used. This method dates back to the ancient Greeks, who believed that an im-
balance of "humors" caused behavior problems and illness. Almost 150 years
ago the statisticians Gauss and Galton developed many of the statistics we use
Prevention 497
today to measure dimensional features. In this form of logic, disorder is attrib-

uted to an individual's differing in degree or amount (for example, 2 standard
deviations) from the norm. Medical examples include blood pressure and
height. Whereas categorical abnormalities and categorical disorders are either
present or absent, dimensional attributes are present in all people but vary
among individuals by amount.
Prevention Strategies
There are two approaches to prevention. The population-based or univer-

sal strategy aims at preventing disorder by focusing on as many members of a
population as possible (for example, lowering salt and cholesterol intake in the
population so as to lower rates of heart attack and stroke). The high risk strategy
intervenes with those at greatest risk (e.g., treating all individuals whose blood
pressure is above 160/90 mm hg) with a goal of preventing morbidity in these
high-risk individuals. The choice of strategy depends on the prevalence of the
disorder in the population (high prevalence favors the population-focused; low
prevalence increases the benefit of a high-risk strategy), the clinical logic used
(categorical logic favors a high-risk strategy; dimensional logic favors the popu-
lation-based approach), the morbidity ofthe condition (prevention for low-mor-
bidity disorders can be justified only if they are common), and a scientific
understanding of what the risk factors are (based in part on relative and attrib-
utable risks). Table 22-1 illustrates these issues.
One important aspect of the dimensional as opposed to categorical disor-
ders is that prevention in dimensional conditions is most effectively accom-
plished by changing the population distribution of a trait or behavior; that is, by
changing the position of as many people as possible toward a "more desirable"
point on the Gaussian curve. Because there are so many more people who score
in this "normal" range for a trait that confers risk than people who score in the
abnormal range, more cases of disorder are prevented among people in the
"normal" range than in the categorically abnormal range. For example, individ-
uals with a systolic blood pressure above 160 mm Hg are at highest risk of
stroke and heart attack. Treating this group for "hypertension," that is, treating
this group as having a categorical abnormality, decreases the number of strokes
and heart attacks that occur in the population. This is an example of the high-
risk categorical model. However, lowering the blood pressure of everyone
whose blood pressure is in the "normal" range (120-160) actually prevents a
greater number of strokes and heart attack, because the number of individuals
Table 22-1. Targets and Models of Prevention

Targeted Universal
Focus individual population

Model individual health public health
Prevalence low high
Logic dichotomous continuous
498 Peter V. Rabins
#of People
80 120 140 160 180

Systolic Blood Pressure
Actual distribution of
1///1111/1 High risk subjects
blood pressure
• _____ Goal of population _ Risk of stroke or heart
strategy attack
+-- Goal of high risk _ _ _ _ _ Desired distribution of

strategy blood pressure
Figure 22-1. Schematic of blood pressure treatment using population and high risk
strategies.
in this group is much greater than in the group with blood pressure greater than
160 and because the linkage between blood pressure and stroke is present in
this "normal" range. Figure 22-1 illustrates this schematically.
These principles have significant implications for prevention in the mental
health field. If linkages between psychological morbidity and specific person-
ality traits, coping styles, living arrangements, socioeconomic conditions, and
common life events (all factors that are distributed in the population in a graded
fashion) are identified, then changing how all individuals behave would be the
most effective way to diminish the prevalence of psychological morbidity in the
community at large. On the other hand, individuals at risk for low-prevalence,
high-morbidity diseases (e.g., schizophrenia, manic-depression, HIV infection)
or at high risk for psychological morbidity because they are in certain work set-
tings, disasters, caregiving situations, or have certain medical illnesses (that is,
conditions for which the categorical mode of logic is most appropriate) will be
helped best by a high-risk strategy.
PREVENTION OF MENTAL DISORDER

AMONG OLDER ADULTS
The Epidemiologic Catchment Area study examined approximately 20,000

Americans during the early 1980s to provide data on the prevalence of mental
disorder in the United States (Robins & Regier, 1991). Figure 22-2 compares
prevalence among persons 60 years old and older with younger individuals.
Several points are notable:
Prevention 499
Any AlcohoV Schizophrenial Cognitive

Disorder Mood Anxiety Drugs Schizophrenilorm m
I pairment
Figure 22-2. One-month prevalence of psychiatric disorders by age. ECA Wave I Data.
First, total prevalence of disorder among the elderly is high. One fifth of older
adults suffer from some form of mental disorder. Second, disorders vary greatly in
their prevalence. Anxiety disorder and cognitive disorder are several times more
prevalent among the elderly than mood disorder, substance abuse disorder, or
schizophrenia. Finally, and perhaps most importantly, all disorders other than
cognitive impairment are less prevalent in the elderly than in the young.
However, these data reflect the categorical logic of the Diagnostic and Sta-
tistical Manual of Mental Disorders (American Psychiatric Association, 1994),
the formal nomenclature proposed by the American Psychiatric Association. If
one takes a dimensional approach and examines the rates of symptoms, a dif-
ferent picture emerges. For example, symptoms of depression become more
prevalent in the elderly. Studies that explain why the elderly have more symp-
toms and less disorder are sorely needed. Also needed are studies to identify
who among older adults are at highest risk and whether strategies aimed at low-
ering risk are efficacious.
Data that demonstrate effective prevention in the elderly are sparse. One
way to decide which strategy for prevention might be most appropriate to study
is to understand prevalence of psychological and psychiatric morbidity in the
population. The following sections review what is known about categories of
mental disorder and about the dimensions of distress and predispositions.
PREVENTION OF CATEGORICAL DISORDERS
Dementia
The dementias provide several examples of successful prevention. Indeed,

some of the greatest advances in prevention have occurred among the demen-
tias. At the beginning ofthe 20th century, neurosyphilis accounted for 15% of
500 Peter V. Rahios
persons hospitalized for mental illness in the United States. Although tertiary
syphilis (syphilis involving the nervous system) still occurs, it is now rare. This
has occurred because of effective secondary prevention that depends on the
prompt tracing of people who have had sexual contact with an infected indi-
vidual and on the use of antibiotics. Surprisingly, the rate of syphilis has not de-
clined dramatically between 1920 and 1990 as can be seen in Figure 22-3. The
success in prevention has been the avoidance of long-term sequelae (tertiary
syphilis) by secondary prevention.
An example of effective primary prevention in dementia is that of pellagra.
This was a common cause of mental illness (including dementia) in the United
States at the beginning of the century. The discovery that pellagra is caused by
vitamin Bs deficiency led to food fortification with B vitamins. This has almost
totally eradicated this disease. This is an example of a low-prevalence disorder
prevented by a population strategy (education and vitamin fortification) that
was practical because it was inexpensive and easy to administer.
Prevalence of vascular dementia (dementia due to blood vessel disease)
varies geographically. The dramatic decline in the rate of stroke and heart attack
that has occurred in the United States over the past 20 years and more recently
in other areas of the world suggests that primary preventim:l of this form of de-
mentia is a possibility and that vascular dementia might decline in incidence.
As discussed earlier, changes in behavior (eating better and exercising more) are
likely responsible for the decline (primary prevention) in stroke. There is also
weak evidence of secondary prevention. Meyer (1986) demonstrated that indi-
viduals with a single stroke who were treated with aspirin and followed for 21/2
years had better cognition than a placebo-treated comparison group. The treated
group also experienced better blood brain flow (as measured by brain scan).
This study suggests the possibility that daily low-dose aspirin might prevent
stroke and, therefore, dementia.
These three examples illustrate several aspects of prevention. Neu-
rosyphilis prevention occurred because a biological treatment, penicillin, be-
400~----------------------------
350+-------~~------------------
300+------r~r------------------
250+-----r---~------------------
..... Cases per
200+---~----~~--------------- 100,000
150~~--------~~-------------
100+-------------~r-------------
50+-----------------~~~--~~~~
30
Ol+----.---r--~----r_--~--~--_,
1920 1930 1940 1950 1960 1970 1980 1990

Year
Figure 22·3. Reported cases of syphillis

Prevention 501
came available and provided a reason for identifying and promptly treating
those infected with the syphilis spirochete. That is, an ill group (the category)
could be treated promptly (secondary prevention). The population-based inter-
vention, encouraging safe-sex practices such as condom use, was not a major
factor, as primary infection rates did not decline before the introduction of peni-
cillin in the 1940s. The successful prevention of pellagra, on the other hand, re-
sulted from a universal intervention (vitamin B fortification, school breakfast
and lunch programs and improved socioeconomic circumstances).
Vascular dementia prevention requires multiple strategies. Primary pre-
vention with both a high-risk strategy (treating high blood pressure and diabetes
aggressively) and population strategy (lowering fat and salt intake and increas-
ing physical activity) coupled with secondary prevention (drugs [aspirin and
anticoagulants] and surgery [coronary bypass surgery and endarterectomies])
will be most successful because the risk factors are dimensional, common, and
responsive to a number of different treatments.
Alzheimer's disease (AD) is by far the most common cause of dementia.
There are no proven prevention strategies at present but there are several tanta-
lizing leads. Head trauma has been confirmed as a risk factor with a relative risk
between 1.5 and 2. Prevention strategies that decrease head injury due to acci-
dents and boxing could decrease the incidence of AD. Several genetic causes
(four have been identified thus far) and genetic modifiers (the APOE-E4 gene)
have been identified. If diet or medication could block or delay the undesirable
actions of these genes most individuals would die before ever developing the
disease. Low education may be another risk factor for AD. If this proves to be
the case then improved early-life education could be an important pril;nary pre-
vention strategy.
Preliminary research suggests that estrogens and nonsteroidal anti-inflam-
matory medicines (e.g., ibuprofen) might decrease the risk of developing AD.
Because many of the epidemiologic studies demonstrating these effects did not
control for education and social class, their validity is not yet established. It
will be important to determine whether the adverse effects of these drugs
might outweigh whatever protection they provide. Another controversial pre-
ventive factor is activity level. Several studies show that people who maintain
activity are less likely to develop AD; however, it seems most plausible that di-
minished activity is the earliest sign of dementia rather than that inactivity
causes dementia.
Delirium
Delirium is a cognitive disorder in which people are unable to perform

cognitive tasks at their usual level and are also inattentive and drowsy. It is
common among older persons who are hospitalized, in whom prevalence
ranges from 20% to 35% and incidence (that is, the development of delirium
during the hospitalization) is approximately 10% to 15%. Having a dementia
is the highest risk factor (relative risk is approximately 5). The dementia is not
causative but is a predisposing factor. Strategies that identify individuals at
high risk (low cognitive score, older age, weight, more medications, history of
502 Peter V. Rabios
alcoholism) and then carefully monitor them might prevent delirium (primary
prevention) or allow earlier recognition and more prompt treatment (second-
ary prevention).
Mood Disorder
There is no evidence that mood disorder can be primarily prevented. How-

ever, research shows that injury to the left anterior quadrant of the brain due to
stroke greatly increases the risk of developing major depression following
stroke (Robinson, Kubos, Starr, Rao, & Price, 1984). A trial of antidepressants or
psychotherapy or both in persons with a new stroke in this area of the brain
would be intriguing, but this study has not been carried out yet.
Secondary prevention of mood disorder is possible, on the other hand. Ear-
lier recognition of depression through better training for clinicians and the use
of self-administered screening questionnaires are secondary preventive strate-
gies. One study (German, Shapiro, & Skinner, 1985) demonstrated that provid-
ing the scores from screening questionnaires to clinicians improved the
treatment of elderly individuals.
Suicide is a behavior with several causes. Rates in the United States are
highest in older persons and have increased more among persons 80 years old
or older than in any other groups (MMWR, 1996). Approximately 60% of sui-
cides in older adults are due to depression and another 30% occur in individu-
als with substance abuse disorder (Conwell, Olsen, Caine, & Flannery. 1991).
Studies in both the United States and Great Britain suggest that most persons
who commit suicide have seen a medical practitioner several weeks prior to the
suicide attempt. These data suggest that primary prevention of suicide is best
accomplished by earlier and more effective recognition of both depression and
substance abuse (a secondary prevention high-risk strategy). This will require
improved clinician training (to recognize disorders and to assess for suicidal
ideation) that is best provided by mental health practitioners.
Depression and manic-depression (unipolar and bipolar mood disorder)
are frequently recurrent. Frequency of relapse can be decreased by psychother-
apy and medication (tertiary prevention).
PREVENTION OF DIMENSIONAL
DISORDERS
Overview
The relationships among personality, coping strategies, life change, and

"stress" are complex. Studies have not shown that "prophylactic" interventions
such as preretirement or stress management training have demonstrable pre-
ventive benefits (although these certainly appear to benefit some individuals),
nor has prevention been shown to prevent prolonged grief reactions. In one
well-designed community-based trial, individuals randomized to group treat-
Prevention 503
ment after the death of a loved one were not less symptomatic than individuals
who did not receive treatment (Vachon, Lyall. & Rogers, 1980).
On the other hand, caregivers of persons with chronic illnesses have
demonstrated decreased emotional distress with treatment. To date, 9 of 11 con-
trolled trials of interventions that target caregivers of persons with dementia
have proven effective in improving caregiver mood and morale (Rabins, 1996).
Interventions that provide caregivers with emotional support are more effective
than those that offer only educational information. The combination of emo-
tional support and education is most effective. Two studies have shown that
nursing home placement can be delayed by caregiver interventions. These tri-
als have generally studied caregivers of individuals attending memory assess-
ment centers, day treatment centers. or similar facilities. Therefore, it is
possible that the study participants may have been "high-risk" individuals.
Nevertheless, there is good evidence to support secondary preventive efficacy
for support groups of the chronically ill.
An intriguing set of experiments carried out in the United States by
Rodin and colleagues (Rodin, 1986; Rodin & McAvay, 1992) suggests that
"giving control" to older individuals can improve their psychological well-be-
ing. In one study implemented in a nursing home, individuals who were al-
lowed to tend to plants and make decisions regarding them fared better
emotionally than those who did not. Although these studies have been car-
ried out in narrowly defined populations and have relied on interventions
and responses that may be culturally specific, the results show the important
impact that environmental design can have on behavior and mood and sug-
gest that environments that maximize the choice of older persons can prevent
demoralization and inactivity.
Degree of memory decline associated with usual aging varies widely
(Schaie, 1994). Providing instruction on memory enhancement strategies may
lessen the amount of decline (Schaie, 1994).
Substance Abuse Disorder
Alcohol abuse remains a problem in late life although many studies suggest
that prevalence of alcohol use and abuse declines in late life. Several studies
suggest that this is due to the declining health of some individuals. Alcohol
abuse makes up the bulk of substance abuse disorders in the elderly now but it
is quite likely that as younger cohorts grow old the abuse of narcotics, stimu-
lants, hallucinogens, and other drugs will increase.
Although some individuals, particularly women, first develop alcohol
problems in mid or late life, substance abuse usually begins early in life. Thus,
primary prevention efforts aimed at young individuals will likely be the most
effective way of preventing late-life substance abuse disorder. Further research
is needed to demonstrate effectiveness of currently available treatments in the
elderly. Clearly, however, because many individuals do not respond to these
therapies, more effective treatments are needed. It is not known whether older
adults respond better to some types of therapy than to others.
504 Peter V. Rabins
SUMMARY
Most categorical mental disorders are uncommon and their genesis is mul-
tifactorial. Therefore, population-based primary preventive strategies for dis-
eases such as manic-depression and schizophrenia are unlikely to be developed
in the near future. On the other hand, dimensional and behavioral disorders,
such as age-associated memory changes, sadness, distress due to caregiving,
substance abuse, and obesity are common enough that population-based strate-
gies could be effective.
Secondary preventive strategies for individuals and groups of individuals
at high risk for vascular dementia, delirium, and suicidal behavior are effective,
as are tertiary preventive strategies that improve long-term care of persons with
mood disorder, schizophrenic disorders, substance abuse disorder, anxiety dis-
order, and behavioral symptoms accompanying dementia, and the emotional,
educational, and social support of caregivers. As Meyer warned 80 years ago, it
is important that we neither oversell nor trivialize prevention. Well-designed
research is our best hope for developing interventions that can prevent mental
morbidity and identify those at risk.
REFERENCES
Conwell, Y.• Olsen, L., Caine, E. D., & Flannery, C. (1991). Suicide in late life: Psychological autopsy
findings. International Psychogeriatrics, 3, 59-66.
German, P. S., Shapiro, S., & Skinner, E. A (1985). Mental health ofthe elderly: Use of health and
mental health services. Journal of the American Geriatics Society. 33, 246-252.
Meyer, A. (1915). Where should we attack the problem of prevention of mental defects and mental
disease? Survey. 34, 557-560.
Meyer, J. S., Judd, B. J., & Tawaklna, T. (1986) Improved cognition after control ofrisk factors for
multi infarct dementia. Journal of the American Medical Association, 256, 2203-2209.
Mrazek, P. J., & Haggerty, R. J. (Eds.). (1994). Reducing risks for mental disorders: Frontiers for
preventive intervention research. Washington. DC: National Academy Press. Institute of
Medicine.
Morbidity and Mortality Weekly Report [MMWR]. (1996). Suicide among older persons-United
States, 1980-1992. MMWR, 45, 3-6.
Rabins, P. V. (1996). Caring for persons with dementing illnesses: A current perspective. In L. Hes-
ton (Ed.), Progress in Alzheimer's disease and similar conditions (pp. 277-289). Washington,
DC: American Psychiatric Press.
Robins, L. E. & Regier. D. A. (Eds.). (1991). Psychiatric disorders in America. New York: Free Press.
Robinson. R. G.• Kubos. K. L.• Starr. L. B.• Rao, K.. & Price. T. R. (1984). Mood disorders in stroke pa-
tients: Importance oflocation oflesions. Brain, 107, 81-93.
Rodin. J. (1986). Aging and health: Effects of the sense of control. Science, 233, 1271-1276.
Rodin. J.• & McAvay. G. (1992). Determinants of change in perceived health in a longitudinal study
of older adults. Journals of Gerontology. 47, 373-384.
Schaie. K. W. (1994). The course of adult intellectual development. American Psychologist, 49,
304-313.
Vachon. M. L. S .• Lyall. W. A. L.• Rogers. J. et a1. (1980). A controlled study of self-help interven-
tion for widows. American Journal of Psychiatry. 137,1380-1384.
Wilson. L. B.• Simpson. S.• & McCaughey. K. (1983). The status of preventive care for the aged: A
meta-analysis. In S. Simpson. L. B. Wilson. J. Hermalin. & R. Hess (Eds.). Aging and preven-
tion (pp. 23-38). New York: Haworth.
CHAPTER 23
Minority Issues
SHERRILL L. SELLERS, JAMES S. JACKSON,
AND CHERYL BURNS HARDISON
INTRODUCTION
This chapter addresses the influence of cultural and ethnic factors on health
among minority group older persons. Because of the existence of more exten-
sive national data (Stanford & Du Bois, 1992), we focus primarily on Hispanic
American, African American, and American Indian elderly. We realize that
these three groups do not capture the full diversity of material, social, and life
experiences among the vast array of minority elderly groups n.
s. Jackson, Al-
bright, et al., 1995). They are, however, a sizable subset of the rapidly growing
population of minority older adults. We are unable in the space allotted for this
chapter to examine the complicated heterogeneity among even these three
groups. Thus, we direct our attention primarily to common factors that may in-
crease risk of, or enhance resilience to, poor physical health and mental health
outcomes. Specifically, we examine the meaning and significance of minority
group status to physical and psychological health and suggest that a culturally
sensitive theoretical framework for research and interventions with ethnic mi-
nority older persons must attend to (1) sociohistorical context, (2) significance
of minority group status, and (3) cultural reality of life among ethnic and racial
minorities. These three recommendations evolve from assuming a life-course
perspective on aging. A life-course perspective considers the unfolding of lives
n.
through time S. Jackson & Sellers, 1997). This perspective is particularly im-
portant for considering the lives of ethnic minority older persons in whom ex-
periences in adolescence and early adulthood, as well as cohort and period
events, influence health trajectories, health behaviors, and attitudes toward
health professionals (Riley, 1996).
SHERRILL L. SELLERS, JAMES S. JACKSON, AND CHERYL BURNS HARDISON • Program for Research on Black
Americans. Institute for Social Research. University of Michigan. Ann Arbor. Michigan 48106-1248.
505
506 Sherrill L. Sellers et al.
The chapter is divided into four sections. In the first section, we briefly de-
scribe some of the major demographic characteristics of the three cultural
groups. In the second, we present recent data on the physical and mental health
status of these elderly. In the third section, we address caregiving. The objective
of this section is to frame the discussion of caregiving in a ethnic and cultural
context, furthering the development of culturally sensitive care for minority el-
derly (J. S. Jackson, Burns, & Gibson, 1992). We conclude with specific recom-
mendations for researchers, policymakers, and health care providers.
ELDERLY ETHNIC MINORITIES IN THE

UNITED STATES-DEMOGRAPHICS
Anticipating the primary recommendations, we suggest the need for more

research and services grounded in a sociohistorical context. The health status of
American Indian older people provides an important illustration. McCabe and
Cueller (1994) suggest that American Indian elderly live in worse material con-
ditions than those of majority group older persons in the United States. Thus,
some of the problems associated with older age affect American Indian older
adults at an earlier chronological age than majority elders and earlier than some
better-off minority group older persons. Specifically, Manson and Callaway
(1988) found that a 50-year-old American Indian confronts the health chal-
lenges of a 65-year-old White American. Hence, the central concepts of geron-
tology, age, aging, elderly, must include individual biography, diversity within
and between ethnic group members, and sociohistorical context (Riley. 1996).
Several terms have been used to describe racial and ethnic groups. Some
focus on a group's relationship with others; other terms focus on language, re-
gion of origin, and dietary habits. The concepts of culture, race, and ethnic
group are prominent in the study of ethnic minority aging. Yet, there is consid-
erable conceptual confusion over the use of these terms. We use the term ethnic
minority elderly to convey age, ethnicity, and sociohistorical status. We begin
with a conceptualization of minority and majority. The majority or dominant
group is defined as the group that has power and uses it to control social insti-
tutions and processes for its own benefit (Blauner, 1972). A minority group is
defined as a group that is distinguishable on the basis of skin color, language,
culture, religion, or other observable characteristics (Wirth, 1945). Minority
groups have less power than the majority group; they control fewer resources
and have unequal access to social rewards (King & Williams, 1995). Often a dis-
tinguishing feature of a minority group is its culture. We adopt the definition of-
fered by Swidler (1986), who defines culture as a symbolic vehicle of meaning,
including beliefs and rituals as well as informal practices such as language and
activities of daily life. In other words, culture refers to the ways of living that
people devise to meet biological and psychosocial needs. These ways of living
are passed down through the generations, but may vary over time and across re-
gions. Culture is not independent; rather, it develops from the social environ-
ment in which individuals are embedded. What is most salient for our purpose
is the recognition that individuals' culture will influence their definition of ill-
ness, perceptions of symptoms, and health behaviors (Levine & Gaw, 1995;
Minority Issues 507
Snow, 1983). Ethnicityrefers to connectedness based on shared norms and val-

ues. It is often used interchangeably with race. However, ethnicity and race
technically have very different meanings. We prefer the term ethnicity, primar-
ily because it focuses attention on social and historical context, rather than
questionable genetic and biological differences. We refer to those individuals
over age 65 as ethnic minority elderly. The term, although not lyrical, aims to
convey both ethnic and sociohistorical status. In addition, we use the terms
Black, rather than African American, and American Indian rather than Native
American, to be consistent with census reports.
Four groups have been identified as ethnic minorities: Blacks. Hispanic
Americans, Asian Americans, and American Indians (including American In-
dians, Eskimos, and Aleuts). It is estimated that by the year 2030, of the people
65 years and older, 15% will be members of these four ethnic groups. And, by
the year 2050, ethnic minority elderly will comprise 21 % of the total u.s. pop-
ulation (J. Angel & Hogan, 1994). This chapter presents demographic and epi-
demiologic data for Blacks, Hispanic Americans, and American Indians. 1 Blacks
comprise 12% ofthe total u.S. population and nearly 11 % of this population is
over the age of 60. Projections indicate that by the year 2000, elderly Blacks will
comprise about 8.5% of the total u.s. population age 65 and over and by 2040,
12.5% of that population (Ruiz, 1995).
Hispanic Americans comprise about 8% of the total u.s. population and
are relatively youthful (median age 25.9 compared with 32.5 for total u.S.
population); consequently, the proportion of Hispanic elderly is certain to
increase. Projections suggests that from the years 2000 to 2050, the Hispanic
elderly population will more than quadruple. That is, in the year 2000, His-
panics are expected to comprise 4.9% of the elderly; by 2050 this number is
expected to increase to 11.7% of all elderly (Garcia, 1991). American Indians
comprise about 1 % of the total u.S. population (U.S. Bureau of the Census,
1990), with some 6% being over the age of 65. Compared to other ethnic mi-
nority elderly, much less is known about elderly American Indians. How-
ever, trends and projections suggest that the elderly among these groups will
also increase. According to the 1990 census, there are nearly 2 million Amer-
ican Indians in the United States. Of this group, only 108,000 are over the
age of 65. However, this number represents an increase of nearly 70% since
1980. There are expected to be 276,000 65 years of age and older by 2020 and
467,000 by 2030 (McCabe & Cueller, 1994). Although these projections indi-
cate an increase in ethnic minority elderly, problems related to the census
undercount may actually underestimate the increases (J. Angel & Hogan,
1994).
Considerable heterogeneity exists between and among these ethnic minor-
ity groups. For example, in 1989. 48% of the approximately 1 million Hispanic
elderly were of Mexican descent. Cuban (18 %), Puerto Rican (11 %). Central
and South American (8.4%), and "Other Hispanic" (15%) comprise the
'We have excluded Asian Americans from detailed discussion because of the relative dearth of
national estimates on this population. as compared with the other three groups. For an excel-
lent review of the health status of Asian Americans see the Stanford Geriatric Center Paper
Series.
remaining groups (J. Angel & Hogan. 1994). Factors such as urbanicity. accul-
turation. education. and socioeconomic status make generalization across
groups tenuous. For example. in 1987. 91 % of the elderly Hispanic population
resided in urban areas. compared with 83% of Black elderly. 72% of White el-
derly. and 54% of American Indian elderly (John. 1994; Villa. Cuellar. Gamel.
&Yeo.1993).
Nevertheless. commonalities among the ethnic minority elderly also exist.
Poverty. gender-related issues. and household living arrangements are particu-
larly salient examples. Specific income and poverty rates vary. but the pattern
is similar across ethnic minority elderly. In 1990. about 10% of all White el-
derly lived in poverty. Also in 1990. median income for Hispanic elderly was
$7.060 (somewhat above the poverty line). while slightly more than 20% of His-
panic elderly had incomes below the poverty line. Similar data for Black el-
derly indicated that more than 30% of this population was below the poverty
level (Ruiz. 1995). American Indians had similar income and poverty patterns.
with incomes slightly higher than those of elderly Blacks. but slightly less than
those of Hispanic elderly (McCabe & Cuellar. 1994). For American Indian elders
the poverty level varied by urbanicity. Those residing in urban areas had lower
poverty rates (25%) compared with their rural counterparts (39%) (Baker &
Lightfoot. 1995).
Gender is also an important risk factor for poverty among ethnic minority el-
derly. Women comprise 58% of the elderly population. but nearly 74% of the el-
derly poor are women (Taeuber. 1992). Poverty is particularly high among black
American elderly women; for those 75 years of age and older. poverty rates are
2.5 times that of majority women (43.9% compared with 17.3%) (Ruiz. 1995).
Further. because of differences in longevity and mortality in general. elderly
women outnumber elderly men (Herzog. 1989). In 1990. for individuals between
the ages of 65 and 74. the gender ratio was 71 Black men to 100 Black women.
For Hispanic elderly. the ratio for Puerto Rican elderly was 1 to 1; for Mexican
American elderly the ratio was 91 men to 100 women (J. Angel & Hogan. 1994).
The gender ratio for American Indian elderly closely resembles that of black el-
derly with 77 men to 100 women at ages 65 to 74; the ratio declines to 59 to 100
after age 85 (McCabe & Cuellar. 1994). Given these statistics. we believe that it is
essential for researchers. policy makers. and program providers to incorporate
considerations of the intersection of ethnicity and gender into their theorizing.
policies. and programs related to ethnic minority elderly.
Household living arrangements illustrate the similarities and differences
among ethnic minority elderly. The most common household arrangement
among ethnic minority elderly is to live with a spouse. Black elderly. however.
do not follow this pattern. in part because of higher rates of marital disruption
throughout the life course. Approximately 30% of Black elderly live alone. a
pattern similar to that of majority elderly (J. Angel & Hogan. 1994). Most eth-
nic minority elderly live in multigenerational families. Lopez and Aguilera
(1991) found that more than 75% of Hispanic elderly lived with other family
members compared with 67% of White elderly and 63% of Black elderly. In a
study that examined factors that influenced community living arrangements of
unmarried White and minority elderly. Black and Hispanic elderly were less
likely to live alone. regardless of health status (R. Angel. Angel. & Himes.
Minority Issues 509
1992). R. Angel and colleagues (1992) also found that old age, low levels of ed-
ucation and income, and having more children contributed to elderly living
with others rather than alone.
PHYSICAL HEALTH
Demographic projections suggest that the proportion of ethnic minority el-

derly will increase in the coming decades. These elderly are more likely to be
female, to live with family members, and to be of lower socioeconomic status.
Such factors in turn influence the physical and mental health status of ethnic
minority elderly. This section selectively reviews the physical health status of
ethnic minority elderly. The specific health topics include mortality rates,
chronic illness conditions (e.g., arthritis, diabetes, hypertension), and leading
causes of mortality (e.g., diseases of the heart, cancer, stroke).
One of the more important differences between ethnic minority elderly and
their majority counterparts is their longevity. In 1995, the life expectancy at
birth was 73.8 years for White males and 80 years for White females, compared
with 64.5 years for Black males and 74.3 years for Black females. Hispanic men
and women have life expectancy rates comparable to majority elderly, 74.9
years for men and 82.2 years for women. For American Indians the life ex-
pectancy at birth is 71.5 years for males and 80.2 years for females (U.S. Bureau
of the Census, 1996). (Authors' note: We conservatively report the middle as-
sumption figures.)
Based on age-specific mortality rates, it appears that a mortality crossover
occurs at some point between the ages of 65 and 85 for Blacks, Hispanic Amer-
icans, and American Indians. This crossover indicates that ethnic minority el-
derly who live to reach these ages will live, on average, longer than their
majority counterparts. Blacks, for example, are at greater risk of dying at every
age, until after the age of 75, when their life expectancy becomes greater than
that of Whites (Richardson, 1990). For American Indians the crossover occurs
after age 65 (John, 1994). Several scholars have attempted to explain the mor-
tality crossover phenomenon genetically, as an artifact of age misreporting, or
as an environmental-biological interaction related to successive mortality
sweeps in different age groups among vulnerable minority populations (e.g.,
Gibson & Jackson, 1992; J. J. Jackson, 1985; Manton, Poss & Wing, 1979). The
empirical evidence in support of these speculations is surprisingly limited. For
Blacks, in the past few decades the age at which the crossover occurs has in-
creased, suggesting largely socially contextualized, rather than mainly genetic,
causes (Richardson, 1990).
With the exception of some Asian American groups, ethnic minority el-
derly generally have poorer health status when compared with Americans of
European descent. Coupled with the fact that almost 85% of those aged 65 or
greater report at least one chronic condition, it is clear that ethnic minority el-
derly are at risk for chronic conditions. The most common chronic conditions
include arthritis, hypertension, and diabetes (Herzog, 1989). For example, ap-
proximately 50% of the Black elderly population report having some form of
arthritis (Cohen & Van Nostrand, 1995).
Rates of hypertension are highest among Blacks, followed by Hispanics,

American Indians, and then White Americans (Villa et a1., 1993). Among Black
elderly, hypertension affects almost 37% of males and 64% offemales (Richard-
son, 1990). Research by Sherman James and colleagues (James, Hartnett, & Kals-
beek, 1983; James, Strogatz, Wing, & Ramsey, 1987) suggests an important
cultural component in the high prevalence of hypertension among Blacks.
James and colleagues suggest that Blacks' sheer determination even in the face
of overwhelming odds (John Henryism) may be a risk factor for hypertension.
Other researchers have highlighted the impact of racism and discrimination
(J. S. Jackson et a1., 1996).
Compared with majority elderly, there is a greater prevalence and inci-
dence of noninsulin-dependent diabetes among ethnic minority elderly. Blacks
over the age of 65 have almost three times the incidence of diabetes compared
with majority elderly (Richardson, 1990). Prevalence of diabetes in Mexican
and Puerto Rican populations is almost double that of Whites, and this preva-
lence increases with age. Diabetes is the fifth leading cause of death among
American Indians (Indian Health Service, 1991). Diabetes is also a contributing
factor in other diseases and health complications including blindness, stroke,
heart disease, and kidney failure (John, 1994).
Richardson (1990) notes, "essentially blacks die of the same diseases as
whites (diseases of the heart, cancer, and cerebrovascular diseases), but at an
earlier age ... " (p. 5). Among Hispanic Americans, mortality rates for specific
causes vary by national origin. Using 1980 census data, Rosenwaike (1987)
found that Puerto Rican-born males had the highest rates of death from heart
disease, compared with Cuban-born and Mexican-born. For Hispanic women,
those who were Cuban-born had the lowest rates, while Puerto Rican-born
women had the highest rates (Rosenwaike, 1987). John (1994) reported that ac-
cording to the Indian Health Service, the leading causes of mortality among
American Indian elderly were heart diseases, malignant neoplasms (cancer),
cerebrovascular diseases (stroke), pneumonia, diabetes, and accidents.
The leading cause of death for all older adults is cardiovascular disease.
Villa and colleagues (1993) noted that although cardiovascular mortality is de-
clining, the decline has been less dramatic for Hispanic elderly and is still the
leading cause of death. During 1985-1987, more than 35% of American Indian
elderly died from diseases of the heart (John, 1994). John (1994) reported that
heart disease was also the leading cause of death among American Indians aged
45 to 64.
Cancer rates vary by ethnic group and type of cancer. According to the Of-
fice of Minority Health Resource Center (1988), Black males have the greatest
likelihood of dying from cancer, compared with all other groups. Villa and col-
leagues (1993) reported that compared with the total older U.S. population, His-
panic elderly had decreased risk of breast cancer and increased risk of liver,
pancreatic, stomach and cervical cancers. Cervical cancer among Hispanic
women more than 65 years of age was particularly high. Villa and colleagues
(1993) speculated that this increase may be, in part, one effect of the lower like-
lihood of older Hispanic women to have Pap tests. The investigators suggest that
this lesser likelihood reflects a cultural emphasis on personal privacy. Among
American Indian elderly, cancer is the seconding leading cause of death, ac-
Minority Issues 511
counting for 17.5% of all deaths during 1985-1987 (John, 1994). Lung cancer is
particularly problematic and is associated with the prevalence of smoking.
Among Black and American Indian elderly, cerebrovascular disease is the
third leading cause of death (Richardson, 1990; John, 1994). Compared with
other Hispanic groups, Rosenwaike (1987) found that Mexican-born elderly had
the highest rate of cerebrovascular disease mortality; Cuban-born elderly had
the lowest rate. He speculated that these "differences may be attributed to mi-
grant selection and within-group lifestyle differences. Specifically, compared
with more recent immigrants of Hispanic origin, pre-1980 immigrants from
Cuba were a select group from the higher social classes (Rosenwaike, 1987).
Debates surrounding genetic versus social factors are particularly promi-
nent with regard to the pattern of mortality among ethnic minority elderly. The
high prevalence of diabetes and hypertension suggests the possibility of genetic
causes. However, there is also a clear link between these illnesses and socio-
cultural factors, such as diet and exercise. Further, obesity is a leading risk fac-
tor for a number of poor health outcomes, including diabetes, hypertension, and
coronary heart disease, and is particularly prevalent among ethnic minority el-
derly women (Richardson, 1990). Yet, there is very little research on cultural at-
titudes toward obesity. Such research is essential. To be successful, efforts to
reduce morbidity and mortality among ethnic minority elderly must consider
cultural factors such as food preferences and sedentary lifestyles, as well as
structural factors such as limited financial resources and racial discrimination.
MENTAL HEALTH
Mental health is, in part, a cultural construction, and is subject to consid-

erable interpretation and speculations regarding its origins, illness prevention
strategies, and treatment options. Mental health research is currently domi-
nated by a disease model and clinically based studies (Vega & Rumbaut, 1991).
This emphasis is particularly problematic for research on minority mental
health in general, and ethnic minority elderly in particular. Ethnic minority el-
derly may associate mental health with mental illness and are likely to view
mental illness as something of which to be ashamed (Baker & Lightfoot, 1995).
They may be less likely to seek assistance (J. S. Jackson & Wolford, 1992). As
Wykle and Kaskel (1991) add, underutilization of mental health resources may
reflect differences in cultural attitudes. Ethnic minority elderly are less likely
than majority elderly to mention mental or emotional problems during physi-
cian visits. In addition, mental health problems may be masked or confounded
by physical health issues. Kasl and Berkman (1981) suggest that compared with
the situation in younger individuals, physical and mental health may be more
closely related among the elderly. Further, some research has reported major
health problems and depression to be highly associated (Brown, Ahmed, Gary,
& Milburn, 1995; Stanford & Du Bois, 1992). In their community study of Black
adults, Brown and colleagues (1995) found that among those reporting depres-
sion, 75% indicated having major physical health problems.
Miranda (1991) estimated that 15% to 25% of all older persons have some
form of mental health problem, either dementing diseases or major mental
disorder. This figure skyrockets to an estimated 70% to 90% for those older
adults in institutional settings (Knight, Santos, Teri, & Lawton, 1995). For eth-
nic minority elderly, specific rates of mental illness vary by disorder (Stanford
& Du Bois, 1992). This section presents several mental health outcomes includ-
ing subjective well-being and selected serious mental disorders.
Well-being may be considered a positive measure of mental health
(Lebowitz & Niederehe, 1992). Although there are a number of measures of
well-being, life satisfaction tends to be the one most frequently used (George,
1993). In general, life satisfaction appears to be slightly higher among older per-
sons than among younger people (Rodgers, 1982). Research indicates that level
of life satisfaction varied among ethnic minority elderly. In a recent analysis us-
ing data from the National Survey of Black Americans, J. S. Jackson and Neigh-
bors (1996) found an increase in life satisfaction over a 13-year period, despite
decreases in economic and social resources, across all age groups. They also
found a trend toward older age group members' reporting greater satisfaction
compared with their younger counterparts. In contrast, Andrews, Lynos, and
Rowland (1992) reported that less than half (48%) of older Hispanics were very
satisfied with their lives, compared with 62% of the general population of U.S.
elderly. In a small study of elderly American Indians, Johnson and colleagues
(1986) found a high level of life satisfaction (about 64%). They also found that
objective measures of life satisfaction were less predictive of mental health than
subjective measures. Older American Indians were more likely to equate life
satisfaction with not feeling lonely and good hearing and vision. The authors
speculate that this finding may reflect cultural differences between majority
and American Indian elderly.
Among all older persons, aside from dementing conditions, affective disor-
ders are one of the most common psychiatric problems (Lebowitz & Niederehe,
1992). Rabins (1992), using ECA data, estimated that nearly 6% of all elderly
met the criteria for an anxiety disorder. Prevalence rates for symptoms of anxi-
ety are even higher. Prevalence of depressive disorders are estimated at between
1 % to 2% for all older persons. As with anxiety, rates of depressive symptoms
are estimated at 20% for older adults. Interestingly, in general, ethnic minority
elderly tend to have rates of diagnosed depression that are comparable to their
White counterparts, but report higher rates of depressive symptoms (Brown et
a1., 1995). In fact, symptoms of depression are the most common psychological
symptoms reported by black elderly (Turnbull & Mui, 1995). Several re-
searchers have found high rates of depressive symptoms among Hispanic el-
derly (Markides & Krause, 1986; Stanford & Du Bois, 1992). In a small study of
Hispanic elderly, Lopez-Aqueres, Keep, Plopper, Staples, and Brummel-Smith
(1984) found that 26% of the Hispanic elderly had major depression or dys-
phoria. Surprisingly, Markides and Krause (1986) found that high levels of as-
sociation with children actually increased depressive symptoms among
Hispanic elderly. In one of the few studies that examined the mental health of
American Indians, Manson, Shore, and Bloom (1985) found that, for all age
groups, depression was the most frequently diagnosed problem.
The most common cause of severe cognitive impairment in old age is
Alzheimer's disease (Herzog, 1989). Its incidence for those more than 65 years
of age is estimated at 10.3% (Evans, Funkenstein, & Albert, 1989). Prevalence of
Minority Issues 513
Alzheimer's has been assumed to be the same for majority and minority elderly
(between 5% and 10%), yet, we know very little about the incidence, preva-
lence, or course of Alzheimer's disease among ethnic minority elderly (Stanford
& Du Bois, 1992).
The interrelationship between physical and mental health is very complex
and research in this area is plagued by problems of confounding measures and
cross-sectional designs (Herzog, 1989). For example, research indicates that
members of ethnic minority groups disproportionately "somatize" psychologi-
cal problems. That is, these individuals manifest psychological problems as
physical symptoms. Yet, several symptom checklists used to ascertain the pres-
ence of mental health problems are designed to rule out physical health prob-
lems. This may result in the underreporting of mental health problems among
minority groups (Vega & Rumbaut, 1991). Depressive symptoms provide a strik-
ing illustration. As mentioned previously, ethnic minority elderly tend to have
higher rates of depressive symptoms. Depressive symptoms include factors
such as low self-esteem, dysphoric mood, loss of energy, and difficulty concen-
trating. The same symptoms are associated with physical ailments. Diagnoses
may be directed toward physical conditions when in fact psychological treat-
ment is needed.
Mental and physical health, culture, and sociohistorical context converge
when the relationship between health and stress is examined. For example, eth-
nic minority elderly may reside in areas that place them at increased risk of
crime. Experiences with mugging, purse-snatching, and witnessing violence
may increase anxiety. Chronic anxiety may be associated with stress-related ill-
ness. Further, these factors influence the level and type of exercise and activi-
ties available to elderly in their living environments. Although considerable
research has described an association between stress and health, we know very
little about the relationships between stress and health among ethnic minority
elderly. In addition, we have very limited knowledge of how stress changes
over the life course. Consider an African American male aged 15; he is consid-
ered violent, dangerous, and a threat to others. Now age this individual 50
years. Society now considers him to be less of a threat. We do not know the im-
pact of this racialized stress; that is, whether the individual has become accus-
tomed to alienation, whether the stress has increased vulnerability to other
stressors, or whether racial and age discrimination interact in such a way as to
actually buffer their individual effects.
For ethnic minorities in general, and ethnic minority elderly in particular,
strategies for coping with stress often take religious form (Dressler, 1991).
Prayer may be an appropriate strategy for some health concerns, but may need
to be supplemented with other interventions (Chatters & Taylor, 1989). Physi-
cians, social workers, and other health care specialists may need to be aware of
the cultural context in which symptoms are described and understood (Gaines,
1992). Further, relative to their majority counterparts, mental health service use
among ethnic minorities is low. Wykle and Kasel (1991) suggest that these dif-
ferences may be a reflection of cultural attitude about mental health and mental
health services and treatments. Padgett (1995) notes that despite emphasis by
mental health researchers on a stress and coping approach to understanding
mental health among ethnic minorities, few researchers have applied the stress
514 Sherrill L. Sellers et a1.
paradigm to ethnic minority elderly (J. S. Jackson, Antonucci & Gibson, 1995;
Padgett, 1995).
Finally, considerations of the mental health of ethnic minority elderly must
also address the relationship between culture, etnicity, and misdiagnosis (Ade-
bimpe, 1981; Jeste, Naimark, Halpain, & Lindamer, 1995; Neighbors, 1984; Wade,
1993). Additional research is needed to identify those factors, be they structural
or individual, that affect diagnosis (Littlewood, 1992). It is clear, however, that
for ethnic minority groups, culture, ethnicity, and social context influence symp-
tom manifestation, intervention strategies, and treatment outcomes.
INFORMAL AND FORMAL CAREGIVING
In the previous sections we described indicators of the physical and men-

tal health status of ethnic minority elderly. This section examines current
trends in caregiving. Differences in caregiving patterns between ethnic minor-
ity and White majority are attributed either to cultural or socioeconomic causes.
Lockery (1991) contends that family history and lifestyle differences among mi-
nority groups influence attitudes and expectations of caregiving. Although
there are overlapping similarities, minority families also differ by such factors
as availability of family and friends, amount of contact with support networks,
conditions of immigration, length of residence in the United States, socializa-
tion processes, socioeconomic status (Lockery, 1991), levels of acculturation
and assimilation (Henderson, Guiterrez-Mayka, & Garcia, 1993), and fertility
and family living arrangements (R. Angel et al., 1992). Hence, the widely vary-
ing findings in the literature on the differences in helping patterns between ma-
jority and ethnic minority elderly may reflect the complexity of within- and
between-group differences (Lockery, 1991).
Historically, informal caregiving among family and friends has played a
major role in the care and support of ethnic elderly (J. S. Jackson, Albright, et
al., 1995). Culture plays an important role in the provision of social support,
living arrangements. and other aspects of caregiving. Worobey and Angel (1990)
found that Blacks, Whites, and Hispanics differed in their pattern of living
arrangements after experiencing a disabling event. Whites tended to enter nurs-
ing homes, Blacks continued to live in their predisability situation, and His-
panic elderly lived with family.
There is a growing trend in research on informal support systems among
ethnic minority elderly to challenge assumptions about the existence, as well as
benefits, of the extended family. Existence of widespread, extensive, and effec-
tive family support among ethnic minorities cannot be taken for granted (White-
Means & Thornton, 1990). For example, in a study of Mexican Americans,
Markides, Boldt, and Ray (1986) found that elderly Mexican Americans were not
more likely to be cared for by their family network than elderly majority Ameri-
cans. The authors interpreted this finding by suggesting that environmental
stressors, such as language and low economic status, interfere with cultural and
family support networks that ordinarily would be provided to aging Hispanics.
Furthermore, it is commonly surmised that large extended minority fami-
lies provide sufficient intergenerational support for their members. However,
Minority Issues 515
Lockery (1991) maintains that the notion of available intergenerational support

is built on a number of erroneous assumptions. In particular, this research as-
sumes that most minority families care for their members (Lockery, 1991; Mor-
rison, 1995). Further, researchers who adopt an uncritical view ofthe extended
family often consider evidence of nonformal service use as understandable and
acceptable.
Caregivers of ethnic minority elderly require additional research. One as-
sumption about these caregivers is that they do not use various support groups
or services because they are either self-reliant or already receiving support from
others. In fact, methods used by service organizations to attract caregivers in the
general population have been unsuccessful with minority communities. One
common explanation is lack of trust and familiarity with staffs of organizations
providing such services. For example, minority caregivers seldom attend sup-
port group meetings for those caring for victims of Alzheimer's disease (Levine
& Lawler, 1991). In addition to addressing emotional strains, support groups
provide valuable information for caregivers. Since minority caregivers do not
attend these meetings, they may be ill prepared for legal and financial uncer-
tainties often inherent in caring for the elderly (Levine & Lawler, 1991).
Social work practitioners and researchers are beginning to address the un-
derutilization of services by minority caregivers. One study examined efforts
to involve the Black church and clergy in disseminating knowledge about
Alzheimer's disease and caregivers' support services (Chadiha, Morrow-How-
ell, Darkwa, & MicGillick, 1994). Only when training sessions were incorpo-
rated into previously scheduled meetings were ministers and laypersons
willing to participate. The authors caution that severity of other social problems
may take away from the clergy members' ability to give attention to Alzheimer's
disease (Chadiha et al., 1994). Further, even though African American social
workers were used as recruiters for the study, their outsider status may have af-
fected the participation of ministers and laypersons in the program. Likewise,
the use of culturally sensitive approaches, such as high levels of personal con-
tact and multiple referral sources, along with perseverance, is crucial for re-
cruiting minority caregivers into support groups (Henderson et al., 1993;
Chadiha et al., 1994).
SUMMARY AND RECOMMENDATIONS
In this chapter we have discussed the meaning and significance of aging

and minority group status in considering physical and psychological health. Al-
though there are few well-developed frameworks, it is clear that a culturally
sensitive theoretical framework for research and interventions with ethnic mi-
nority elderly must attend to sociohistorical content, significance of minority
group status, and the cultural reality of ethnic minorities.
Our recommendations are organized with these three principles in mind.
Consideration of sociohistorical context suggests concerns about longevity and
cohort differences (Riley, 1996). One of the most important changes in human
history is our increasing longevity. Through the early part of this century the
life expectancy for adult males hovered around 40 years of age. Changes in
health care, medical technology, decreased infant mortality, and decreased

adult morbidity and mortality have lengthened the life span to 74 years for
White males. Life expectancy for Blacks has improved dramatically. An African
American woman born in 1900 had a life expectancy of 33.5 years. A Black
woman born in 1985 may expect to live 75.3 years. For Black men, the figures
are 32.5 and 65.3 years (Griffith & Baker, 1995). Yet, it is important to remember
that these changes are in our recent history. Longevity has far-reaching impli-
cations for family patterns, service provision, and social policy. Equally impor-
tant, given that increased longevity is a rather recent historical phenomenon,
society is just beginning to create the sociocultural frameworks from which to
understand and negotiate longer life.
In his classic essay on cohort and social change, Ryder (1965) defined a co-
hort in terms of its aggregate biography. Future cohorts of ethnic minority el-
derly will be both similar to and different from previous cohorts (Baker, 1994).
Experience with racial discrimination provides a striking illustration. Blacks
who are now 75 were probably born in the rural South, experienced childhood
poverty, and were middle-aged during the civil rights movement. Contrast this
to Blacks born in 1975, who will be 75 in the year 2050. These individuals in all
likelihood were born in an urban setting, raised in diverse neighborhoods, and
benefited from the opening up of opportunities. We can only speculate about
the effects of a changing racial system on the health and well-being of ethnic
minorities. This is clearly a fruitful area of research.
Minority group status has important implications for the well-being of eth-
nic elderly. It is in this area that the intersection of individual, group, and social
and material context comes to the fore. Two examples illustrate the importance
of considering both the individual and minority group status. The first example
is that of a retired African American male of average weight, whose blood pres-
sure during a routine physical examination appears to be slightly elevated. Is he
a candidate for medication? It is possible, particularly when one considers the
high prevalence of hypertension among African Americans. However, it is also
possible that the individual finds doctor visits extremely stressful, hence the el-
evated blood pressure. Health care providers must learn to balance group indi-
cators with individual biography. A second example involves the financial
hardships that disproportionately affect ethnic minority elderly. The financial
status of ethnic minority elderly has improved, but lags far behind that of their
White counterparts (Chen, 1995). Although individuals may prepare for aging,
large numbers of ethnic minority elderly are employed in areas that do not in-
clude adequate retirement benefits. These older persons depend mainly on So-
cial Security. New cohorts of ethnic minority elderly may have opportunities to
"plan for retirement." Yet, it is also possible that they too will be trapped in em-
ployment settings that preclude setting aside monies for later life.
Consideration of the cultural reality of life among ethnic minority elderly
leads to a number ofrecommendations. Researchers and practitioners will need
to consider the cultural resources available to these elderly. Cultural resources,
such as the Black church, are important points of intervention among African
American elderly (Griffith & Baker, 1995). A second resource, having pride in
the ability to endure adversity, may reflect cultural belief systems that act as an
important buffer for individuals and groups of ethnic minority elderly. A third
Minority Issues 517
resource may come through intergenerational relations. Griffith and Baker

(1995) speculated that lower rates of suicide among African American elderly
in part may be related to their important roles in the family (J. S. Jackson, An-
tonucci, & Gibson, 1995). They noted that suicide rates among ethnic elderly
may be rising, perhaps indicating increasing stressors (J. S. Jackson, Antonucci,
& Gibson, 1995). Related to these increasing stressors, as noted in the discus-
sion of caregiving, ethnic minority families are under growing pressures (eco-
nomic as well as social) and may be compromised in their ability to care for
elderly. The threat to elderly may take the form of exploitation, neglect, or
abuse. Unfortunately, there is limited research on the factors associated with el-
der abuse among ethnic minorities. With the increases in longevity and aging of
the baby boom cohort, research in this area is essential.
No discussion of minority group aging would be complete without consid-
eration of Riley's (1992) concept of structural lag, defined as the mismatch be-
tween social opportunities and individual aging. For ethnic minority elderly,
the mismatch may be particularly severe, such that past and current contextual
influences overwhelm factors that are attributable to aging-related processes.
Old age cannot be divorced from earlier stages of life and nowhere is this
clearer than among ethnic minority elderly. Among several groups of ethnic mi-
nority elderly, most have experienced economic difficulties, inadequate health
care, and the stress of discrimination.
Another consideration is a cultural understanding of health, illness, and
disease (Gaines, 1992; Padgett, 1995). Health and mental health services must
reach out to older minority adults. This outreach should involve multiple com-
munity locations, from primary health centers to churches to the homes of older
adults (J. S. Jackson, Albright, et a1., 1995). These services must be sensitive to
the lifestyles, cultural preferences, behaviors, attitudes, and values of ethnic
racial minorities (J. S. Jackson et a1., 1992), as well as barriers to service use.
Language may be the most pressing barrier to providing accurate diagnosis and
appropriate intervention strategies for ethnic minority elderly. Researchers
have found that, among Blacks, stress is often discussed in a religious idiom,
as "trials and tribulations" (Dressler, 1991). For nonnative speakers of English,
the language barrier is even more problematic. Specifically, a number of ethnic
minority elderly may be unable to speak or read English (Browne & Broderick,
1994). For ethnic minority elderly, inability to articulate symptoms in a manner
prescribed by the dominant culture may result in misdiagnoses. Efforts to in-
crease service use by ethnic minority elderly will need to employ creative
strategies for informing and serving these populations. Using skilled inter-
preters as a standard practice is one strategy for developing culturally sensitive
services. However, caution must be exercised. Interpreters mediate between the
clinician and the patient; an untrained interpreter could create a number of
problems, including misdiagnosis. Nevertheless, judicious use of interpreters,
nontraditional service settings (e.g., the church), and creative outreach and re-
cruitment strategies are approaches that move beyond standard efforts to more
effectively influence the health and well-being of ethnic minority elderly.
Finally, the heterogeneity within and between ethnic minority elderly must
be explored further (J. S. Jackson, Antonucci, & Gibson, 1995). Research on
American Indians and Asian American elderly is especially sparse (Stanford &
Du Bois, 1992). Similarly, our knowledge of the incidence and prevalence of

such important issues as elder abuse is nearly nonexistent among ethnic mi-
nority elderly. Further, gender differences within groups requires more study
(Brown, Milburn, & Gary, 1992). As we have argued elsewhere, gender, socio-
economic, and ethnic minority status cannot be divorced from one another in
fruitfully studying the lives of ethnic minority elderly (Gibson & Jackson, 1992).
The growth in the number of ethnic minority elderly over the next 50 to 75
years will place increasing burdens on family, other informal supports, and for-
mal delivery of material and social services. Close examination of cultural fac-
tors, minority group determined life experiences, and the organization of formal
systems of care will be required in order to provide effective services to the
largest growing segment of the new elderly population. The belief that these
considerations are of secondary importance to the effective organization and
delivery of physical and mental geriatric health care will no longer be possible.
REFERENCES
Adebimpe. V. (1981). Overview: White norms and psychiatric diagnosis of black patients. American
Journal of Psychiatry, 138,279-285.
Andrews. J.. Lynos. B., & Rowland, D. (1992). Life satisfaction and peace of mind: A comparative
analysis of elderly Hispanic and other elderly Americans. Clinical Gerontologist, 11,21-42.
Angel, J., & Hogan. D. (1994). The demography of minority aging populations. In J. S. Jackson, J. Al-
bright, T. P. Miles. M. R. Miranda. C. Nunez. E. P. Stanford. B. W. K. Yee, D. L. Yee, & G. Yeo
(Eds.). Minority elderly: Five goals toward building a public policy base (2nd ed .. pp. 9-12).
Washington. DC: Gerontological Society of America.
Angel, R.. Angel, J.• & Himes., C. (1992). Minority group status. health transitions. and community
living arrangements among the elderly. Research on Aging, 14,496-521.
Baker. F. M. (1994). Psychiatric treatment of older African Americans. Hospital and Community
Psychiatry, 45(1). 32-37.
Baker. F. M.. & Lightfoot, O. (1995). Psychiatric care of ethnic elderly. In A. Gaw (Ed.). Culture, eth-
nicity, and mental illness (pp. 517-552). Washington. DC: American Psychiatric Press.
Blauner. R. (1972). Racial oppression in America. New York: Harper & Row.
Brown. D. R.. Milburn. N. G. & Gary. L. E. (1992). Symptoms of depression among older African-
Americans: An analysis of gender differences. Gerontologist, 32 (6). 789-795.
Brown. D. R.. Ahmed. F.. Gary. L. E.. & Milburn. N. G. (1995). Major depression in a community
sample of African Americans. American Journal of Psychiatry. 152 (3). 373-378.
Browne. C.. & Broaderick. A. (1994). Asian and Pacific island elderly: Issues for social work prac-
tice and education. Social Work. 39. 252-259.
Chadiha. L.. Morrow-Howell. N .. Darkwa. 0 .. & MicGillick. J. (1994). Targeting the black church and
clergy for disseminating knowledge about Alzheimer's disease and caregivers's support ser-
vices. American Journal of Alzheimer's Care and Related Disorders and Research. 9, 17-20.
Chatters. L. M.. & Taylor. R. J. (1989). Age differences in religious participation among black adults.
Journal of Gerontology: Social Sciences, 44. S183-S189.
Chen. Y. P. (1995). Improving the economic security of minority persons as they enter old age. In J.
S. Jackson. J. Albright. T. Miles. M. Miranda. C. Nunez. E. Stanford. B. Yee. D. Yee. & G. Yeo
(Eds.). Minority elders: Five goals toward building a public policy (2nd ed .. pp. 22-31). Wash-
ington. DC: Gerontological Society of America.
Cohen. R. A.. & Van Nostrand. J. F. (1995). Trends in the health of older Americans: United States,
1994. Washington. DC: National Center for Health Statistics.
Dressler. W. (1991). Stress and adaptation in the context of culture: Depression in a southern black
community. New York: State University of New York Press.
Minority Issues 519
Evans. D.. Funkenstein. H.. & Albert. M. (1989). Prevalence of Alzhemier's disease in a community
population of older persons higher than previously reported. Journal of the American Medical
Association. 262. 2251-2556.
Gaines. A. D. (1992). From DSM-I to II-R; Voices of self. mastery and the other: A cultural construc-
tivist reading of U.S. psychiatric classification. Social Science and Medicine. 35 (1). 3-24.
Garcia. A. (1991). The changing demographic face of Hispanics in the United States. In M. So-
tomayor (Ed.). Empowering Hispanic families: A critical issue for the ·90·s. (pp. 21-38). Mil-
waukee. WI: Family Service America.
George. 1. (1993). Economic status and subjective well-being: A review of the literature and an
agenda for future research. In N. Culter. D. Gregg. & M. P. Lawton (Eds.). Aging. money and life
satisfaction (pp. 69-99). New York: Springer.
Gibson. R. C.. & Jackson. J. S. (1992). The black oldest old: Health. functioning and informal sup-
port. In R. M. Suzman. D. P. Willis. & K. G. Manton (Eds.). The oldest old (pp. 321-340). New
York: Oxford University Press.
Griffith. E.. & Baker. F. M. (1995). Psychiatric care of African Americans. In A. Gaw (Ed.). Culture.
ethnicity. and mental illness (pp. 147-173). Washington. DC: American Psychiatric Press.
Henderson. J.• Guiterrez-Mayka. M.• & Garcia. J. (1993). A model of Alzheimer's disease support
group development in African-American and Hispanic populations. Gerontologist. 33.
409-414.
Herzog. R. (1989). Physical and mental health in older women: Selected research issues and data
sources. In A. R. Herzog. K. Holden. & M. Seltzer (Eds.). Health and economic status of older
women (pp. 35-91). Amityville. NY: Baywood.
Indian Health Service. (1991). Trends in Indian health. U.S. Department of Health and Human Ser-
vices. Public Health Services. Washington. DC: U.S. Government Printing Office.
Jackson. J. J. (1985). Race. national origin. ethnicity. and aging. In R. B. Binstock & E. Shanas (Eds.).
Handbook of aging and the social sciences (pp. 264-303). New York: Van Nostrand Reinhold.
Jackson. J. S .• & Neighbors. W. (1996). Changes in African American resources and mental health
1979 to 1992. In H. Neighbors & J. Jackson (Eds). Mental health in Black America (pp.
189-212). Thousand Oaks. CA: Sage.
Jackson. J. S.. & Sellers. S. 1. (1997). Psychological. social. and cultural perspectives on minority
health in adolescence: A life-course framework. In D. Wilson. J. Rodrigue. & W. Taylor (Eds.).
Health-promoting and health-compromising behaviors among minority adolescents (pp.
29-54). Washington. DC: American Psychological Association.
Jackson. J. S .. & Wolford. M. L. (1992). Changes from 1979 to 1987 in mental health status and help-
seeking among African Americans. Journal of Geriatric Psychiatry. 25. 15-67.
Jackson. J. S .. Burns. C.• & Gibson. R. (1992). An overview of geriatric care in ethnic and racial mi-
nority groups. In E. Calkins. P. J. Davis. A. B. Ford. & P. R. Katz (Eds.). Practice of Geriatrics
(2nd ed .. pp. 57-64). Philadelphia: Harcourt Brace Jovanovich.
Jackson. J. S .. Albright. J.. Miles. T. Po, Miranda. M. R.. Nunez. C.. Stanford. E. P.. Yee. B. W. K.. Yee.
D. 1.. & Yeo. G. (Eds.). (1995). Minority elderly: Five goals toward building a public policy base
(2nd ed.). Washington. DC: Gerontological Society of America.
Jackson. J. S .• Antonucci. T. C.. & Gibson. R. C. (1995). Ethnic and cultural factors in research on
aging and mental health: A life-course perspective. In D. K. Padgett (Ed.). Handbook on eth-
nicity. aging and mental health (pp. 22-46). New York: Greenwood/Praeger.
Jackson. J. S.. Brown. T.. Williams. D.. Torres. M.. Sellers. S.• & Brown. K. (1996). Perceptions and
experiences of racism and the physical and mental health status of African Americans: A thir-
teen-year national panel study. Ethnicity and Disease. 6. 132-147.
James. S .• Hartnett. S .• & Kalsbeek. W. (1983). John Henryism and blood pressure differences among
black men. Journal of Behavioral Medicine. 6. 259-278.
James. S .• Strogatz. D.. Wing. S .• & Ramsey. D. (1987). Socioeconomic status. John Henryism. and
hypertension in blacks and whites. American Journal of Epidemiology. 126.664-673.
Jeste. D. V.• Naimark. D.• Halpain. M. C.• & Lindamer. L. A. (1995). Strengths and limitations ofre-
search on late-life psychoses. In M. Gatz (Ed.). Emerging issues in mental health (pp. 72-96).
Washington. DC: American Psychological Association.
John. R. (1994). The state of research on American Indian elders' health. income security. and social
support networks. In J. S. Jackson. J. Albright. T. Miles. M. Miranda. C. Nunez. E. Stanford. B.
Yee. D. Yee. & G. Yeo (Eds.). Minority elders: Five goals toward building a public policy base
(2nd ed.• pp. 46-58). Washington. DC: Gerontological Society of America.
Johnson. F.• Cook. E.• Foxall. M., Kelleher. E., Kentopp, E.• & Mannlein, E. (1986). Life satisfaction
of the elderly American Indian. International Journal of Nursing Studies. 23(3). 265-273.
KasI. S.• & Berkman. L. (1981). Some psychosocial influences on the health status of the elderly: The
perspective of social epidemiology. In J. L. McGaugh & S. B. Kiesler (Eds.). Aging, biology and
behavior (pp. 345-385). New York: Academic.
King. G.• & Williams, D. (1995). Race and health: A multidimensional approach to African-Ameri-
can health. In C. Benjamin. I. Amick. S. Levin. A. R. Tarlov. & D. C. Walsh (Eds.). Society and
Health (pp. 93-130). New York: Oxford University Press.
Knight. B.• Santos. J., Teri. L.• & Lawton. M. P. (1995). Introduction: The development of training in
clinical geropsychology. In B. Knight, L. TerL P. Wohlford, & J. Santos (Eds.). Mental health
services for older adults (pp. 1-8). Washington. DC: American Psychological Association.
Lebowitz. B. D.• & Niederehe. G. (1992). Concepts and issues in mental health and aging. In J. E. Bir-
reno R B. Sloane. & G. D. Cohen (Eds.). Handbook of men tal health and aging (2nd ed .• pp.
3-26). New York: Academic.
Levine. ] .. & Lawlor. B. (1991). Family counseling and legal issues in Alzheimer's disease. Psychi-
atric Clinics of North America. 14.385-396.
Levine, R, & Gaw, A. (1995). Culture-bound syndrones. Culture Psychiatry. 18(3). 523-536.
Littlewood. R (1992). Psychiatric diagnosis and racial bias: Empirical and interpretative ap-
proaches. Social Science 8' Medicine, 34, 141-149.
Lockery. S. (1991). Family and social support: Caregiving among racial and ethnic minority elderly.
Generations. 15, 58-62.
Lopez, C., & Aguilera, E. (1991). On the sidelines: Hispanic elderly and the continuum of care.
Washington, DC: National Council of La Raza.
Lopez-Aqueres, A., Keep, B.• Plopper. M., Staples, F., & Brummel-Smith, K. (1984). Health needs of
the Hispanic elderly. Journal of the American Geriatric Society. 32, 191-198.
Manson. S., & Callaway, D. (1988). Health and aging among American Indians. Issues and chal-
lenges for the biobehavioral sciences. In S. M. Mason & N. Dinges (Eds.), Health and behavior:
A research agenda for American Indians (pp. 160-210). Denver: University of Colorado
Health Sciences Center.
Manson, S., Shore. J.• & Bloom.]. (1985). The depressive experience in American Indian communi-
ties: A challenge for psychiatric theory and diagnosis. In A. Kleinman & Y. Good (Eds.), Cul-
ture and depression (pp. 331-368). Berkeley, CA: University of California Press.
Manton. K.. Poss, S., & Wing. S. (1979). The black/white mortality crossover: Investigation from the
perspective of the components of aging. Gerontologist, 19.291-300.
Markides. K.. & Krause. N. (1986). Older Mexican Americans. Generations, 10, 31-34.
Markides. K.. Boldt. ].• & Ray. L. (1986). Sources of helping and intergenerational solidarity: A three
generation study of Mexican Americans. Journals of Gerontology. 41, 506-511.
McCabe. M.• & Cuellar, J. (1994). Aging and health: American Indian/Alaska native elderly (2nd
ed.). Working Paper Series No.6. Palo Alto, CA: Stanford Geriatric Education Center.
Miranda. M. (1991). Mental health services and the Hispanic elderly. In M. Sotomayor (Ed.). Em-
powering Hispanic families: A critical issue for the '90s. (141-154). Milwaukee. WI: Family
Service America.
Morrison, B. (1995). A research and policy agenda on predictors of institutional placement among
minority elderly. Journal of Gerontological Social Work, 24, 17-28.
Neighbors, H. (1984). The distribution of psychiatric morbidity in African Americans: A review and
suggestions for research. Community Mental Health Journal. 20. 5-18.
Office of Minority Health Resource Center. (1988). Closing the gap: Cancer and minorities. Office of
Minority Health. Public Health Service. Washington, DC: U.S. Department of Health and Hu-
man Services.
Padgett, D. (1995). Concluding remarks and suggestions for research and service delivery. In D. Pad-
gett (Ed.). Handbook on ethnicity, aging, and mental health (pp. 304-319). Westport, CT:
Greenwood.
Rabins, P. (1992). Prevention of mental disorder in the elderly: Current perspectives and future
prospectus. Journal of the American Geriatrics Society. 40, 727-733.
Minority Issues 521
Richardson. J. (1990). Aging and health: Black American elderly. Stanford. CA: Stanford Geriatric
Education Center Working Paper Series No 4. Ethnogeriatic Reviews.
Riley. M. (1992). Aging in the twenty-first century. In N. Culter. D. Gregg. & M. P. Lawton (Eds.). Ag-
ing. money and life satisfaction (pp. 23-36). New York: Springer.
Riley. M. (1996). Age stratification. In J. E. Birren (Ed.). Encyclopedia of gerontology: Age, aging and
the aged (pp. 81-92). New York: Academic.
Rodgers. W. (1982). Trends in reported happiness within demographically defined subgroups.
1957-78. Social Forces, 60,826-842.
Rosenwaike.1. (1987). Mortality differentials among persons born in Cuba. Mexico. and Puerto Rico
residing in the United States. 1979-1981. American Journal of Public Health. 77,603-606.
Ruiz. D. (1995). Profile of ethnic elderly. In D. Padgett (Ed.). Handbook on ethnicity. aging, and
mental health (pp. 3-21). Westport. CT: Greenwood.
Ryder. N. (1965). The cohort as a concept in the study of social change. American Sociological Re-
view. 30. 843-861.
Snow. L. F. (1983). Traditional health beliefs and practices among lower class black Americans.
Western Journal of Medicine, 139(6). 820-828.
Stanford. E. P.• & Du Bois. B. C. (1992). Gender and ethnicity patterns. In J. E. Birren, R. B. Sloane.
& G. D. Cohen (Eds.). Handbook of mental health and aging (2nd ed .• pp. 99-117). New York:
Academic.
Swidler. A. (1986). Culture in action: Symbols and strategies. American Sociological Review, 51,
273-286.
Taeuber. C. (1992). Income and poverty trends for the elderly. Population Division. Bureau of the
Census. U.S. Department of Commerce. Washington. DC: U.S. Government Printing Office.
Turnbull. J.• & Mui. A. (1995). Mental health status and needs of black and white elderly: Differ-
ences in depression. In D. Padgett (Ed.). Handbook on ethnicity. aging, and mental health (pp.
73-98). Westport. CT: Greenwood.
U.S. Bureau ofthe Census. (1990). Population estimates by age, sex, race, and Hispanic origin: 1980
to 1988. Current population reports. (Series P-25. No. 1045). Washington. DC: U.S. Govern-
ment Printing Office.
U.S. Bureau ofthe Census. (1996). Population projections of the United States by age, sex, race, and
Hispanic origin: 1995 to 2050. Current population reports. (Series P-25. No. 1130). Washing-
ton. DC: U.S. Government Printing Office.
Vega. W.. & Rumbaut. R. (1991). Ethnic minorities and mental health. Annual Review of Sociology,
17,351-383.
Villa. M.• Cuellar. J.• Gamel, N.. & Yeo. G. (1993). Aging and health: Hispanic American elderly (2nd
ed.) SGEC Working Paper Series Number 5 Ethnogeratic Reviews. Stanford. CA: Stanford Geri-
atric Education Centers.
Wade. J. (1993). Institutional racism: An analysis ofthe mental health system. American Journal of
Psychiatry. 127. 329-355.
White-Means. S.I.. & Thornton. M. C. (1990). Ethic differences in the production of informal home
health care. Gerontologist, 30 (6). 758-768.
Wirth. L. (1945). The problem of minority groups. In R. Linton (Ed.). The science of man in the
world crisis (pp. 99-117). New York: Columbia University Press.
Worobey. J.. & Angel. R. (1990). Functional capacity and living arrangements of unmarried elderly
persons. Journal of Gerontology: Social Sciences, 45, 95-101.
Wykle. M.. & Kaskel. B. (1991). Increasing the longevity of minority older adults through improved
health status. In J. S. Jackson. J. Albright. T. Miles. M. Miranda. C. Nunez. E. Stanford. B. Yee.
D. Yee. & G. Yeo (Eds.). Minority elders: Five goals toward building a public policy base (2nd
ed .. pp. 32-39). Washington. DC: Gerontological Society of America.
CHAPTER 24
Physical Activity
WARREN W. TRYON
INTRODUCTION
There are at least five reasons for geropsychologists to be interested in physical

activity. The first reason is that activity is a prominent life-span developmental
personality variable. We will see that stable individual activity differences be-
gin prenatally, are universally recognized as a major dimension of infant tem-
perament, comprise a facet of introversion which is recognized as an important
personality trait by all investigators, and remain stable throughout adult life.
The ability to ambulate and lead an active life assumes greater importance with
advanced age. Perception of health in oneself and others is directly propor-
tional to physical activity. Active lifestyle, therefore, constitutes an important
individual difference for geropsychologists.
A second reason for geropsychologists to be interested in physical activity
is its connection with physical health. Evidence is reviewed that exercise pro-
motes both physical and mental health in older people as well as middle-aged
or young adults. Older people benefit proportionally, but to a lesser absolute de-
gree, than younger people, but it is never too late to assume a more active life
style. Active lifestyle is directly related to physical health.
A third reason for geropsychological interest in activity is that exercise ap-
pears to improve mental health and cognitive functioning. Activity seems to re-
duce depression, which is quite frequent among older people given loss of job
through retirement, loss of friends and relatives through death, and a clearer
recognition of the limits of their life span. Exercise also seems to improve cog-
nition, perhaps through better blood flow. Chronic diseases, such as lung dis-
ease, arthritis, heart disease, and other ailments, reduce activity and alter
previously established individual activity differences. Physical disease and in-
jury modify preexisting personality differences. These factors alter the activity
distributions with age.
WARREN W. TRYON • Department of Psychology, Fordham University, Bronx, New York 10458-5198.
523
524 Warren W. Tryon
A fourth reason for geropsychologists to be interested in physical activity is

that sleep disorders are directly proportional to age and because sleep can be
productively studied via actigraphy. The Sleep-Onset Spectrum (SOS) is de-
scribed to properly understand the perspective actigraphy provides regarding
sleep. Validation of wrist actigraphy for sleep assessment is addressed and ap-
plications to sleep disorders experienced by the elderly are considered.
A fifth reason for geropsychologists to be interested in physical activity is
to better understand developmental changes in circadian rhythm. Our biologi-
cal clocks deteriorate over time and some disorders of aging can be understood
in these terms. Core body temperature defines the strongest circadian rhythm;
activity level is the second most prominent circadian rhythm. Actigraphy
makes it easy to obtain high-quality activity data every minute of the day and
night for up to 22 consecutive days from people under natural conditions. Data
collection can continue by downloading and reinitializing the actigraphs.
PERSONALITY
Activity is a prominent life-span developmental personality variable from

before birth, through infancy and childhood, into adulthood and old age.
Prenatal
Activity is arguably the first personality variable to form stable individual

differences. Eaton and Saudino (1992) review 14 studies validating maternal fe-
tal counts. Maternal counts tend to underestimate instrument detectable fetal
movements. However, correlations between maternal and instrumented
recorded counts ranged from .32 to .99; six articles reported correlations of .97
to .99. Eaton and Saudino (1992) studied daily fetal movement counts obtained
once per week from 7 A.M. until 11 P.M. from 46 women with normal pregnan-
cies. Significant and substantial between-fetus differences (F(45. 495) = 174.33,
p < .0001) were found. Individual stability, calculated as a generalizability co-
efficient and interpreted as a reliability coefficient, based on recordings for 1
week was found to be .93.
Infancy
Goldsmith and colleagues (1987) considered four approaches to tempera-

ment and concluded that all theorists agree that activity level and emotionality
are valid, primary, and replicable dimensions of temperament. Zuckerman
(1991, pp. 7-8) reported that activity is one of nine defining features of tem-
perament. Activity consistently emerges as an important variable in Zucker-
man's (1991) discussion of genetic influences during infancy and early
childhood (pp. 111-116). For example, by age 9, activity is among the tempera-
ment facets with the highest heritability ratios. Kagan and Snidman (1991) also
consider motor activity to be an important aspect of infant temperament.
Physical Activity 525
Adulthood
The index of Zuckerman's (1991) book identifies 43 of 428 pages (10%)

wherein the importance of activity to an understanding of the psychobiology
of personality is discussed. Buss and Plomin (1984) consider activity to be one
of the "Big 3" personality factors. Zuckerman (1991, pp. 28-29) identifies ac-
tivity as one of five primary personality factors. Costa and McCrae (1992) con-
clude that activity develops into a facet of Extraversion in the Five Factor
Model of personality. They characterize the activity (E4) Extraversion facet as
follows: "A high Activity score is seen in rapid tempo and vigorous movement,
in a sense of energy, and in a need to keep busy. Active people lead fast-paced
lives. Low scorers are more leisurely and relaxed in tempo, although they are
not necessarily sluggish or lazy" (p. 17).
Old Age
The five personality factors, including the activity facet, remain stable
throughout adulthood into old age (Costa & McCrae, 1980, 1994) where the ac-
tivity factor assumes greater prominence as activity lifestyle (Hultsch, Ham-
mer, & Small, 1993). Activity impairment is an important aspect of disability
and is therefore of increasing importance throughout late life. Insofar as inac-
tivity is unhealthy, death selects out inactive people thereby skewing the ac-
tivity distribution to the right. Disease counters this trend by reducing activity
level in the more active people who survive thereby skewing the activity dis-
tribution to the left. The relative effects of these two processes are presently
unknown. Consequently, we do not know how their joint effect alters activity
distributions in the elderly. Disease mediated inactivity probably has a nega-
tive effect on one's psychological state. Inactivity is, to this extent, a causal an-
tecedent of depression in the elderly and consequently an important mental
health concern.
ACTIVITY AND DISABILITY
Hypokinetic Disease
Kraus and Raab (1961) coined the term "hypokinetic disease" to describe a
spectrum of physical and mental disorder induced by inactivity. It is interesting
that disabilities normally associated with aging can be partially produced in
young healthy persons by protracted inactivity. Bortz (1982) discovered impor-
tant parallels between normal aging and inactivity regarding the cardiovascular
system, blood components, body composition, metabolic and regulatory func-
tions, and the nervous system.
Motor control decreases with age and these changes are most noticeable
on more demanding tests (Joseph & Roth, 1988; Wallace, Krauter, & Campbell,
1980). Joseph and Roth (1993) summarized experimental evidence indicat-
ing that motor performance deteriorates primarily as the result of impaired
526 Warren W. Tryon
dopaminergic function due to striatal dopamine receptor loss. Receptor den-

sity increase in rats has been achieved through the administration of estrogen
or prolactin.
Active Life Style

General
O'Brien and Vertinsky (1991) point out that women outlive their male
counterparts but often these extra years of life entail chronic illness and dis-
ability. These authors indicate that" ... evidence is rapidly accumulating that
physical mobility is a critical survival need for the elderly" (p. 348). "Indeed,
about 50% of what we currently accept as aging is now understood to be hy-
pokinesia, a disease of 'disuse,' the degeneration and functional loss of muscle
and bone tissue" (p. 348, emphasis added). The long-term benefits of exercise
on health· are both broad and substantial.
Active life expectancy (ALE) refers to the years before disability alters one's
functional status (see Manton, Stallard, & Liu, 1993). ALE is an important deter-
minant of the health and service needs of persons over 65 years of age. Mobility
is recognized as an essential component of self-care. Guralnik and Simonsick
(1993) report that "the assessment of functional status and disability is now
widely employed by those caring for older patients and those studying the health
problems of older populations" (p. 3). Disability regarding activities of daily liv-
ing increases rapidly after age 65. Guralnik and Simonsick (1993) report that 22%
of women and 15% of men over age 65 are sufficiently disabled that they either
need help to live at home or are institutionalized. By age 75, the sex difference in
disability is pronounced; and at age 85, 62% of women and 46% of men need
help to live at home or are in a nursing home. Woollacott (1993) observes that
many older adults lose the ability to ambulate outside their home because they
cannot maintain their balance on uneven surfaces and in moving vehicles such as
a bus o~ train. Frail elderly nursing home residents are frequently very inactive.
Siu and colleagues (1993) underscored the need to measure functioning in
the very old and concluded that most measures were developed on middle-aged
and young-old persons. Their objective was to develop a measure of function-
ing in old-old persons. Manton and colleagues (1993) observed that single ALE
estimates cannot address individual disability effects over time nor can they re-
flect intervention effects. Multiple measurements are required for these pur-
poses. Actigraphy, discussed in the next section, is especially suited for
longitudinal activity measurement. Gerety and colleagues (1993) complained
that existing assessment devices are insensitive to individual differences. Ac-
cordingly, they embarked on creating a more suitable Physical Disability Index
(PDI). Their goals were to detect individual differences and changes in func-
tioning over time. They wanted to avoid ceiling and floor effects and sought to
reduce reporting bias. They chose tasks to measure strength, range of motion,
balance, mobility, and fine motor activities and administered this test battery to
259 nursing home residents aged 60 to 98 (mean 78.3 years). Time for comple-
tion ranged from 46 to 83 min (mean 60 min).
Actigraphy
Technological advances provide gerontologists with instruments that can
quantify activity. Tryon (1985,1991) reviewed instruments for measuring activ-
ity. Tryon and Williams (1996) introduced a new fully proportional actigraph
capable of quantifying 128 levels of activity, averaging the results over user-
selectable, often i-min, epochs, and storing the result in memory 24 hours per
day for 22 consecutive days before filling memory. Measurements can be made
every second if desired with the consequence that memory fills up 60 times
faster than when using i-minute recording epochs. Even faster recording rates
are now possible. Ambulatory Monitoring Inc. (Ardsley, NY) and Computer Sci-
ence and Applications, Inc. (Shalimar, FL) offer rapid sampling actigraphs ca-
pable of making ten readings per second (10 Hz).
Actigraphy solves the problems of (1) sensitivity to individual differences
and (2) avoidance of floor and ceiling effects for two types of behavioral sam-
ples. First, one can attach an actigraph to the subject while they perform pre-
scribed movements such as the standardized assessments mentioned earlier.
For example, Rosnow and Breslau (1966) assessed walking up and down stairs
to the second floor and walking a half mile. Less demanding tests include walk-
ing across the room (Guralnik & Simonsick, 1993) and walking an 8-foot course
(Guralnik et 01., 1994). Such tests could be better quantified by attaching an
actigraph to the waist, wrist, and/or ankle. Measuring behavior on a 128-point
scale 10 times each second and recording the average each second means that
60 data points are obtained each minute. These large data sets ensure that (1) in-
dividual differences will arise and (2) no subject will get all zeros (floor effect)
or all values of 128 (ceiling effect).
The second type of behavioral sample is a 24-hour sample of the subject's
natural behavior for 7, 14, or 21 days. The longer the sample the more repeat-
able each subject's mean value, the clearer individual differences will become.
Some subjects will undoubtedly be more variable than others. Because the stan-
dard error of the mean equals the standard deviation of the sample divided by
the square root of the sample size, more certainty can be obtained for a more
variable subject by collecting more data points through extending the observa-
tion period. Hence, statistical significance can be found for even small individ-
ual differences. Floor effects cannot occur because everyone moves to some
degree over a 1- or 2-week period. It is impossible for a person to wear an activ-
ity monitor for this period of time without recording any activity. Ceiling effects
also cannot occur because even young healthy people cannot continuously emit
the maximum activity detectable by modern actigraphs 24 hours a day for 7,14,
or 21 consecutive days.
Beyond the question of behavioral sample size is sample representative-
ness. If the person's routine is about the same each day, then a i-week behav-
ioral sample constitutes seven replications of a representative day. This
conclusion assumes that the 7 chosen days are representative of days in
general for that subject. If the person works or volunteers on Mondays
and Wednesdays in the same setting, then a i-week sample contains only
2 volunteer days but 5 nonvolunteer days. Then there is the question of
whether weekend days are comparable to weekdays. From the perspective of
528 Warren W. Tryon
representativeness, a 2-week sample is reasonably small. Brief behavioral

samples taken during standardized testing may not be representative; the gen-
eralizability of such results may thus be questionable. This is not to say that
activity measurements taken during standard conditions do not generalize;
rather, the burden of proof is on the investigator who wishes to so generalize.
Consequently, standard test results should be compared with 2-week, or
longer, samples to demonstrate generalizability.
The site of attachment is also important. Waist activity primarily reflects
ambulation. Since a person's center of gravity is near the waist, movement of
this site is among the most energy-intensive movements we typically make.
Wrist movement also occurs during ambulation, except when carrying some-
thing, but it also reflects purposive activities while seated. Wrist activity clearly
discriminates sleep from wake (Tryon, 1991, 1996). The ankle is a third possi-
ble site of attachment but is the least preferred because the jarring associated
with footfalls can produce artificially large readings. The investigator selects
one or more sites of attachment depending upon the objective.
It is possible to combine the standardized test and naturalistic behav-
ioral sample approaches by instructing or prompting subjects to perform
specified activities at prescribed times each day. Seven to 14 repeated mea-
surements would result if the required exercises were performed just once
each day for 1 or 2 weeks. Two or three times this many measurements could
be obtained if subjects were instructed to repeat these behaviors two or three
times each day.
Activity assessments taken at yearly or monthly intervals would enable one
to calculate inverse growth (decline) curves thereby quantifying the rate at
which activity decreases over time. This approach is the reverse of what the pe-
diatrician does when placing infants on a growth curve to anticipate adult
stature and weight.
A potential limitation of obtaining 24-hour activity levels is that they quan-
tify habitual activity rather than the person's capacity for activity. It must al-
ways be the case that the person is capable of being as active as they have been
measured to be. Therefore, habitual activity establishes a lower bound on ac-
tivity capacity. Evaluation of an upper limit can be accomplished by motivating
the person to increase or maximize activity during a test period. However, ha-
bitual activity level may be more important to psychological and physical
health than maximum ability to be active.
Actigraphy provides a noninvasive and cost-effective technology for ob-
taining extended activity lifestyle measurements. Gathering data about self-
reported activity is an inexpensive alternative. However, Sidney and
Shephard (1977) reported substantial discrepancies between self-reported
and measured activity. This is to be expected for several reasons. People are
largely unaware of their activity level because their attention is focused on
what they are doing rather than on the mechanics of how they are doing it.
Second, devices can quantify physical forces more accurately and consis-
tently than can humans. However, people are better at judging quality of ac-
tivity such as whether their activity was productive or symptomatic behavior
such as pacing or restlessness.
PHYSICAL HEALTH
Activity relates to health in two reciprocal ways. First, activity appears to

reduce the risk of death by disease and seems to promote physical health. El-
derly people evaluate their own health, and the health of others, in terms of ac-
tivity (Burnside, 1978; Gueldner & Spradley, 1988) with more active persons
perceived as healthier. Second, disease and depression reduce activity and
actigraphy can be used to quantify this change.
The important role activity plays in maintaining health is clarified through
forced inactivity. Kraus and Raab's (1961) concept of "hypokinetic disease" is
important here. It is interesting that disabilities normally associated with aging
can be partially produced in young healthy persons by protracted inactivity.
Palmore (1970) suggested that exercise is the health practice most strongly as-
sociated with longevity in the elderly.
Exercise Reduces Disease Risk
Activity has beneficial effects for those with coronary artery disease (Ober-
man, 1985; Paffenbarger & Hyde, 1984; K. E. Powell, Thompson, Caspersen, &
Kendrick, 1987; Salonen, Puska, & Tuomilehto, 1982), obesity (Colvin & Olson,
1983; Hoiberg, Bernard, Watten & Caine, 1984; Marston & Criss, 1984; Westover
& Lanyon, 1990), colon cancer (Slattery, Schumacher, Smith, West, & Abd-
Elghany, 1988), and all-cause mortality in both young (Blair et aI., 1989;
Bouchard, Shepard, Stephens, Sutton, & McPherson, 1990; Fox, Naughton, &
Haskell, 1971), middle-aged (Leon, Connett, Jacobs, & Rauramaa, 1987; Morris
et aI., 1973; Morris, Everitt, Pollard, Chave, & Semmence, 1980), and older
adults (Blumenthal, et aI., 1989; Cunningham, Rechnitzer, Howard, & Donner,
1987; A. C. King, Taylor, Haskell, & DeBusk, 1989). Blair and colleagues (1989)
reported that the decline in death rates with increased levels of fitness is most
pronounced in older persons.
Magnus, Matroos, and Strackee (1979) reported a significant negative asso-
ciation between sustained light physical exercise, mainly walking, cycling, or
gardening, and acute coronary events. Of the 473 subjects, 220 walked, cycled,
or gardened less than 4 hours per week. Smoking was reported to weaken the
benefits of exercise. Redwood, Rosing, and Epstein (1972) reported that light
physical exercise, such as walking, lowers blood pressure. Slattery, Jacobs, and
Nichaman (1989) analyzed 17- to 20-year mortality data on 3,043 subjects and
reported that small increases in activity confer substantial protection against
death by coronary disease. Expending just 250 Kcal per week through exercise
was sufficient to gain benefit. This level of activity corresponds to just 10 min
per day of light activity such as walking on a flat surface at 3 mph. In sum, a
small amount of activity taken consistently is healthier than being entirely
sedentary. Many older people are able to engage in activity at such a nonaerobic
activity level.
Paffenbarger, Hyde, Wing, and Steinmetz (1984) reported that the rate of
all-cause mortality per 10,000 man-years of observation among 16,936 Harvard
530 Warren W. Tryon
alumni between 1962 and 1978 was 84.8 for those expending less than 500
calories through exercise per week, 66.0 for those expending 500 to 1,999 calo-
ries per week, and 52.1 for those expending 2,000 or more calories per week (p
< .001). The mortality rates for total cardiovascular diseases associated with the
three exercise levels are 39.5, 30.8, and 21.4 (p < .001). The rates for death from
respiratory disease across the three exercise levels are 6.0, 3.2, and 1.5 (p
< .001). The rates for death from all cancers are 25.7, 19.2, and 19.0 (p < .026).
The benefits of exercise also extend to mental health: The rates for death by sui-
cide are 5.1, 3.2, and 2.9 (p < .049). As a control condition, death by accidental
means was unrelated to exercise. The three rates were 3.6, 3.9, and 3.0 (p <
.147). The 2,000-calorie-per-week activity expenditure reduces to just 286 calo-
ries per day, which is within the capacity of many people. Similar results are
presented by Paffenbarger, Wing, and Hyde (1978). It is not difficult to expend
500 calories per day through activity.
Paffenbarger, Hyde, Wing, and Hsieh (1986) further reported on the 16,936
Harvard alumni sample and revealed that walking 9 or more versus 3 miles per
week reduced the risk of death by 21 %. Persons expending 3,500 calories per
week had an all-cause mortality rate half that of those expending less than 500
calories per week. Expending 2,000 calories or more per week reduced all-cause
death risk 28% below those expending less than 500 calories per week.
Energy expenditure can be measured by a waist-worn accelerometer-based
device retailed under the name Caltrac ™ (Muscle Dynamics, 201000 Hamilton
Avenue, Torrance, CA 90502) (Tryon, 1991a, p. 49). The author has worn this
device for 610 days and finds that his daily energy expenditure due to activity
ranges from 173 to 1,116 Kcal with many values in the 500 Kcal range, 645 Kcal
being the midrange value. This results in a minimum of 173 x 7 = 1,211 Kcal
per week and more likely 500 x 7 =3,500 Kcal per week. Caltrac also calculates
estimated basal and total calories expended.
Exercise Promotes Physical Health
It has been suggested that the deterioration of the central nervous system
with age is partly the result of chronic mild hypoxia (Gibson & Peterson, 1982)
due to atherosclerosis (Bierman, 1978; Mintz & Mankovsky, 1971) and inactive
life styles (deVries, 1983). Fox and colleagues (1971) conclude that exercise
may improve the quality of life as much or more than it may extend life.
Ades, Waldmann, and Gillespie (1995) demonstrated that elderly people
can benefit from physical conditioning. They compared spontaneous recovery
to formal reconditioning in 23 postcoronary bypass surgery patients and 23
control subjects. The mean age was 68 years for both groups. The training pro-
tocol was for 3 hours of activity per week for 3 months. Only the experimental
groups displayed evidence of conditioning such as lowered heart rate.
Glucose tolerance deteriorates with aging (Davidson, 1979). The normal de-
cline of activity and increase in adiposity with age adversely affect glucose me-
tabolism. Endurance exercise has clearly been shown to reduce insulin in
young people (D.S. King et a!., 1988; LeBlanc, Nadeau, Richard, & Tremblay,
1981) and in master athletes (Rogers, King, Hagberg, Ehsani, & Holloszy, 1990;
Seals et 01., 1984). Although these studies have demonstrated reduced plasma
insulin in response to an oral glucose challenge, the more definitive hyper-
glycemic clamp procedure was not used. Kirwan, Kohrt, Wojta, Bourey, and
Holloszy (1993) used this improved procedure to evaluate the effects of en-
durance exercise training on 12 subjects (5 men, 7 women) aged 60 to 70 years
and a young normally active control group of 7 men and 5 women 23 to 26
years old. Exercise primarily entailed walking and running on an indoor track
or treadmill supplemented with stationary cycling and rowing for 45 minutes,
plus warm-up and cool-down, 4 days per week for 9 months. Results indicated
a significant decline in plasma insulin concentration.
Uncertainty remains over the proper intensity of activity. Minor, Hewett,
Webel, Anderson, and Ray (1989) noted that lower-intensity exercise programs
may result in improved day-to-day functioning of patients with rheumatoid
arthritis and osteoarthritis in the absence of substantial increases in maximal
oxygen uptake. However,Paffenbarger and Hale (1975) studied coronary mor-
tality among 6,351 men aged 35 to 74 years over a 22-year period or until age
75. They report that repeated bursts of high energy activity protects against
coronary mortality. Data were analyzed in terms of Kcal per minute without ref-
erence to duration. Perhaps relatively short periods of exertion can have sub-
stantial health benefits.
Haskell (1985) observed that the general guidelines for prescribing exercise
are based more on what is required to improve physical conditioning than what
is necessary to prevent disease or extend longevity. Previous investigators have
assumed that exercise requirements are the same for both criteria but this may
not be the case. A plausible explanation is that it is easier for investigators to
demonstrate improved physical conditioning than it is to demonstrate disease
prevention or longevity increases. Hence, investigators choose to demonstrate
the effects of exercise on physical performance. It is possible that frequent par-
ticipation in low-intensity exercise has both psychological and physical benefits.
Life Extension
Goodrick (1980) reported that exercised male rats outlived their nonexer-
cised controls by 19.3%. Exercised female rats outlived their non exercised con-
trols by 11%. Holloszy, Smith, Vining, and Adams (1985) reported that
exercised males rats outlived unexercised controls by 11.8%. Holloszy and
Schechtman (1991) placed this figure at 9.6%. One problem with these studies
is that exercised male rats do not increase caloric intake to compensate for ex-
ercise and therefore resemble calorie restricted animals; calorie restriction has
been known since 1935 to increase life span (Holloszy, 1993). Female rats in-
crease food intake to compensate for energy expended through activity. There-
fore, Holloszy (1993) compared 60 exercised female rats with 64 sedentary
controls. Exercise increased average life expectancy by about 9%. This effect
was observed for every subject except for the first and last to die. The first exer-
cised animal and first nonexercised animal to die had the same life span. The
same was true for the last animal to die in both groups. They died at the same
age. Hence, no increase in maximum longevity was observed. At every other
532 Warren W. Tryon
rank ordered position, the exercised animal lived longer than the nonexercised
animal. Consequently, exercise produces a very consistent effect.
Paffenbarger and colleagues (1986) reported that the number of years hu-
man life was extended through activity depended on the age at which subjects
entered their study. Subjects entering between the ages of 35 and 39 lived 2.51
years longer if they expended 2,000 or more calories through exercise each
week than if they expended less than 500 calories per week. This longevity in-
crease reduced to 0.42 years for those who entered the study between the ages
of 75 and 79. On average, activity promoted longevity for all subjects by 2.15
years. Harvard alumni are not typical of the U.S. population. Their age-specific
death rates are roughly half those for White males in the United States. This fact
makes the present results conservative. Samples with higher death rates may
benefit considerably more through activity increases than did this healthier
Harvard sample.
Quantify Recovery
Major surgery such as coronary artery bypass or hip replacement reduces

activity to zero during the operation. Minor movements return during recovery
as the effects of anesthesia wear off. Nursing efforts are focused toward facili-
tating self-care and ambulation which entail wrist and waist activity. Imple-
mentation of the Prospective Payment System (PPS) in 1984 has motivated
hospital planners to identify patients who can safely be discharged early (Ens-
berg, Paletta, Galecki, Dacko, & Fries, 1993). Activity growth curves can be used
to quantify recovery. Time to achieve preoperative activity can be predicted if
baseline activity measurements are taken prior to surgery either in preparation
for surgery or as part of a routine physical examination.
EXERCISE IMPROVES MENTAL HEALTH
Exercise Reduces Depression
Simons, McGowan, Epstein, Kupfer, and Robertson (1985) critically evalu-

ated the following seven studies. Greist and colleagues (1979) divided 24 men
and women aged 18 to 30 years into a running, time-limited psychotherapy and
time-unlimited psychotherapy for 10 to 12 weeks. Graphic presentation of
Symptom Checklist (SCL-90) results suggested significant and equivalent re-
ductions in depression for subjects in all three groups which makes exercise as
effective as psychotherapy. Greist (1984) divided 60 depressed subjects into an
exercise group, relaxation group, or group therapy. After 12 weeks, SCL-90
scores again were significantly, but equally, reduced for all three groups. Doyne,
Chambless, and Beutler (1983) demonstrated the antidepressive effects of exer-
cise for 4 women using a single subject research design. Doyne, Chambless, and
Beutler (1983) divided 41 women with minor depression into an 8-week exer-
cise group and a control group. Significant reductions in Beck Depression In-
ventory (BDI) scores and Hamilton Rating Scale for Depression scores occurred
for subjects in the exercise but not the control groups. McCann and Holmes
(1984) divided 43 college women into exercise, relaxation training, and no
treatment groups. BDI scores reduced significantly more for the exercisers than
the other two groups. Fremont and Craighead (1984) divided 49 mildly to mod-
erately depressed men and women aged 19 to 62 years into three groups: run-
ning, cognitive therapy, and running plus cognitive therapy for 10 weeks.
Exercise was as effective as cognitive therapy and their combination in reduc-
ing depression.
Martinsen (1984) studied 49 hospitalized depressed men and women aged
17 to 60 years. All subjects received individual psychotherapy and occupa-
tional therapy. Twenty-four subjects also received exercise training. After 9
weeks, patients receiving exercise had Significantly lower BDI scores than did
control subjects. Unfortunately for our purposes, the oldest subject in the
above-mentioned studies was 62. The antidepressive effects of exercise in the
elderly remain to be demonstrated. However, Folkins and Sime (1981) evalu-
ated theory and research relating physical fitness training to psychological vari-
ables in both normal and clinical populations and some of the reviewed studies
entailed geriatric samples that evidenced improvement. Yet, Fillingim and Blu-
menthal (1993) reviewed studies regarding mood and neuropsychological test
effects of aerobic exercise on elderly subjects and concluded that results have
been inconsistent. Recommendations to improve future research include de-
veloping tests that are more sensitive to the effects of exercise.
The following biological mechanism makes it likely that running and other
repetitive exercises are antidepressive for persons of all ages. B. L. Jacobs (1994)
and B. L. Jacobs and Fornal (1993) reported laboratory evidence from cats show-
ing that repetitive activity patterns release serotonin from the Raphe nuclei in
the brainstem. Increasing availability of serotonin by decreasing reuptake is the
way some of the more modern antidepressant medications work. Therefore,
there is a known physical basis that explains how repetitive activity like run-
ning can reduce depression. This finding gives new meaning to the term psy-
chopharmacology. Normally the term refers to the psychological and behavioral
effects of medications. Here we suggest that repetitive activity can release ad-
ditional serotonin. One can self-stimulate with serotonin by running and other
repetitive behaviors such as calisthenics. This finding suggests that compulsive
behaviors, including compulsive activity by anorectics, may be reinforced by
the antidepressive effects of additional serotonin release.
Running is a less viable option for older than younger persons for at least
two reasons. First, knee and foot problems sufficient to contraindicate running
become increasingly common with age. Second, cerebellar dysfunction lead-
ing to instability increases with age. It is well known that balance is impaired
with advancing age (Woollacott, 1993). As a result, risk of injury from falling
increases with age. However, the fact that running appears to have its antide-
pressive effects through repetitive motor actions, central pattern generated
activities, means that less strenuous repetitive activities may also have anti de-
pressing characteristics. Rapidly pedaling an exercycle set to a low or moderate
energy consumption level is one possibility. Movement classes emphasizing
repetitive actions may be another. These movements can be performed in a pool
to further reduce joint stress.
534 Warren W. 1ryon
Exercise Reduces Anxiety
Exercise has been shown to reduce anxiety (Petruzzello, Landers, Hatfield,

Kubitz, & Salazar, 1991) and increase perceptions of personal efficacy (Mc-
Auley, Courneya, & Lettunich, 1991). MCAuley (1992) reported that although
self-efficacy was predictive of adherence to the early stages of an organized ex-
ercise program, previous participation was the best predictor of later adherence
to an exercise program. However, 4 months after the end of an exercise program,
self-efficacy was the best predictor of continued exercise (MCAuley, 1993).
McAuley, Lox, and Duncan (1993) conducted a 9-month follow-up study of a 5-
month structured walking program with 44 (53.5%) of the 82 subjects complet-
ing the program (26 women, 18 men). Results revealed that adherence efficacy
significantly predicted exercise maintenance (r(42) =.43, P < .001) and that pro-
gram attendance significantly predicted efficacy (r(42) = .42, P < .01). Program
attendance was associated with a lower percentage offat (r(42) =-.47, P < .001),
and a lower percentage of fat was associated with higher rate of oxygen uptake
(V02 max) (r(42) =-.46, P < .001).
EXERCISE IMPROVES COGNITION
Clarkson-Smith and Hartley (1989) hypothesized that high-exercise per-

sons would exceed low-exercise persons in cognition, reaction time, working
memory, and reasoning ability but not vocabulary. They tested their hypothe-
sis by interviewing and examining 300 men and women aged 55 to 91. Group
assignment was made on the basis of an extensive interview covering estimated
kilo calories expended per week and the number of hours per week engaging
in strenuous (above 0.1 Kcal/min/kg of body weight) exercise. The high-exer-
cise subjects expended at least 3,100 Kcal per week while the low-exercise sub-
jects expended less than 1,900 Kcal per week. Results showed that the
high-exercise group was more physically fit than the low-exercise group; they
had a significantly higher vital capacity and significantly lower heart rate. Sig-
nificant differences favoring the high-exercise group were found on all three
reasoning tests, two of three working memory tests, and all three reaction time
tests after controlling for age, education, and vocabulary scores. A small but sig-
nificant difference in vocabulary favoring the high-exercise group emerged. The
authors cautioned that uncontrolled differences in diet or other unmeasured
variables could potentially explain the results. The decision to be active is prob-
ably correlated with several other lifestyle changes. However, it is easier to
quantify activity level than other lifestyle changes. If activity level can be used
as proxy for a set of health-related behaviors then high-quality activity mea-
surements can be used to evaluate health status.
Dustman and colleagues (1984) examined the impact of 4 months of aero-
bic exercise training on the neuropsychological function of three groups of sub-
jects. The aerobic exercise group consisted of nine men and four women aged
55 to 68 years. These subjects exercised at 70% to 80% of their maximum age-
adjusted heart rate for individually determined periods of time that became
longer over 4 months of training. An exercise control group of nine men and six
women aged 55 to 70 years participated in strength and flexibility exercises. A
nonexercise control group of nine men and six women aged 51 to 70 years was
tested and retested. Results revealed significant improvement for the aerobic
exercise but not the other two groups on the Critical Flicker Fusion, Digit Sym-
bol, Simple Reaction Time, and Stroop Interference and Total Times.
Gerontologists are interested in separating the effects of normal aging from
disease in elderly patients. This distinction is complicated by the putative re-
lationship between activity lifestyle and cognitive performance. Hultsch and
colleagues (1993) examined the relationships between self-reported activity
lifestyle and cognition in 484 community-dwelling adults (293 women, 191
men) aged 55 to 86 years. Testing was completed in three 2-hour sessions. Re-
sults indicated that the Active Life Style correlated r(482) = -.22, P < .001 with
semantic processing time, r(482) = -.27, P < .001 with comprehension time,
r(482) = .14, P < .01 with working memory, r(482) = .13, P < .01 with vocabu-
lary, r(482) = .21, P < .001 with verbal fluency, r(482) = 26, P < .001 with world
knowledge, r(482) = .18, P < .001 with word recall, and r(482) = .23, P < .001
with text recall. Active lifestyle was also significantly correlated with education
(r(482) = .21, P < .001), gender (r(482) = .33, P < .001; men more active than
women), and age (r(482) = -.20, P < .001; older persons less active than younger
persons). The authors conclude that "Active Life Style is a more powerful pre-
dictor of cognitive performance for the older subjects than for the middle-aged
subjects" (p. P8). Effect size is illustrated by noting that adding Active Life Style
to predictor equations increases explainable variance from 15% to 48%.
Stones and Kozma (1989) investigated the effects of exercise on Symbol
Digit coding performance (given symbols, subjects had to identify digits) in 40
younger (mean age = 21.2 years) and 40 older (mean age = 62.9 years) as a func-
tion of energy expenditure. Subjects expending less than 1.5 Kcal/kg/day were
classified as sedentary; subjects expending more than this amount were classi-
fied as nonsedentary (Stephens, Craig, & Ferris, 1986). The significant exercise
effect favored older subjects. Older exercisers completed the task, on average, in
203.9 (SD = 41.0) seconds versus 242.3 (SD = 63.0) seconds for non exercisers.
Younger exercisers (M = 148.1, SD = 22.6) were essentially equal to non-exer-
cisers (M = 145.9, SD = 19.6).
Hill, Storandt, and Malley (1993) compared the cognitive performance of
87 sedentary subjects receiving 9 to 12 months of exercise with 34 matched con-
trols aged 60 to 73 years. The experimental group tested the same at posttest on
the Wechsler Memory Scale Logical Memory but control subjects tested signif-
icantly lower. The authors concluded that exercise may slow down the effects
of aging on memory.
R. R. Powell (1974) studied the effects of 12 weeks of exercise on the cog-
nitive performance of 13 male and 17 female geriatric mental patients (mean
age = 69.3 yrs). Significant differences on the Progressive Matrices Test and the
Wechsler Memory Scale were reported but not for the Memory-for-Designs test.
EXERCISE ADHERENCE
Dishman (1990) reported that approximately 50% of participants in super-

vised exercise programs drop out. Dishman (1991) critically reviewed 56 stud-
ies designed to increase or maintain exercise. He observed that most studies
536 Warren W. Tryon
have not used direct measures of physical activity or fitness and therefore he
questioned the validity of the findings. Self-report evidence indicates that all
published behavioral and cognitive behavioral interventions produce statisti-
cally significant and clinically meaningful activity increases. Follow-up data
beyond 3 months are generally unavailable.
Knapp (1988) presents a seven-point method for reducing relapse. Situa-
tions that place the person at risk for relapse are identified. Plans are made to
avoid or cope with these high-risk situations. Expectancies of positive outcome
are adjusted to place the consequences of not exercising in proper perspective.
Alternative plans are made for vacationing and when other disruptions of nor-
mal routine are encountered. Preparation is made for the tendency to com-
pletely give up when a brief relapse occurs. The pleasure obtained from
exercise is optimized. Self-defeating dialogues and images pertaining to not ex-
ercising and in favor of inactivity are blocked.
NOCI'URNAL ACTIVITY
Activity assessment is normally associated with diurnal behavior but noc-

turnal activity is of special importance for the elderly. Inactivity is the norm
during the hours that others are asleep. Short low-intensity activity episodes are
not generally disruptive of other persons' sleep. However, pacing and other
forms of hyperactivity are common in patients with Alzheimer's disease (AD)
(Reisberg et al., 1987; Teri, Larsen, & Reifler, 1988; Winograd & Jarvik, 1986).
Some demented patients walk constantly and find it difficult to remain seated
if unrestrained. Although this behavior may be tolerable during the day, it is
quite intolerable during the night and is an important contributing cause of
caregiver burnout leading to institutionalization of the care receiver (Reisberg et
a1., 1987; Sanford, 1975).
SLEEP
Sleep is predominantly defined and studied in EEG terms by polysomnog-
raphers. However, Rechtschaffen (1994), a leading contributor to this field, in-
sists that "physiological measures derive their value as indicators of sleep from
their correlations with the behavioral criteria, not from any intrinsic ontologi-
calor explanatory superiority" (p. 5). He further concludes that "any scientific
definition of sleep that ignores the behaviors by which sleep is generally known
unnecessarily violates common understanding and invites confusion" (p. 4).
Alternative methods primarily entail sleep logs and actigraphy.
Sleep logs are easy to request. However, awareness decreases over the
sleep-onset period thereby depriving subjects of the cognitive resources needed
to discriminate when sleep begins. The perception of sleep onset may largely be
a function of auditory threshold increases blocking out normal sounds. Awak-
enings during the night may entail only partial consciousness. It is, therefore,
not surprising that self-reports do not agree well with objective sleep indices.
Carskadon and colleagues (1976) compared self-reports of sleep with polysom-
nography on 122 subjects over a total of 368 nights. They reported that most
subjects underestimated the time slept and the number of arousals from sleep,
and overestimated the time required to fall asleep.
Activity also has been used to study sleep (Tryon 1991, pp. 149-195). Some
studies use bed or mattress stabilimeters to monitor motility (Kleitman, 1963,
pp. 81-91; Svanborg, Larsson, Carlsson-Nordlander, & Pirskanen, 1990; Webb,
1968, pp. 11-13). Other studies determine sleep onset using active (Birell, 1983;
Bonato & Ogilvie, 1989; Espie, Lindsay & Espie, 1989; Granada & Hammack,
1961; Kelley & Lichstein, 1980; Sack, Blood, Percy, & Pen, 1995; Stickgold &
Hobson, 1994; Thoman, Acebo, & Lamm, 1993) or passive (Franklin, 1981;
Perry & Goldwater, 1987; Viens, De Koninck, Van den Bergen, Audet, & Christ,
1988) behaviors. Actigraphy employs primarily wrist-worn computerized
devices to quantify and record activity at user-specified epochs, often
i-min intervals. Tryon (1991, pp. 149-195; 1996) reviewed studies validating
sleep scoring based on actigraphy. Sadeh, Hauri, Kripke, and Lavie (1995) re-
cently reviewed the actigraphy literature and concluded that "Actigraphy pro-
vides a cost-effective method for longitudinal, natural assessment of sleep-wake
patterns" (p. 300). The Standards of Practice Committee (1995) of the American
Sleep Disorders Association has recently issued guidelines for the clinical use
of actigraphy in evaluating and diagnosing sleep disorders on the basis of Sadeh
and colleagues' (1995) review.
The wrist is the preferred site of attachment because it is more active than
the waist during sleep (J. J. van Hilten, Middelkoop, Kuiper, Kramer, & Roos,
1993). Comparisons ofleft and right wrists have found the left wrist more active
than the right (Webster, Messin, Mullaney, & Kripke, 1982), the right wrist more
active than the left (Sadeh, Sharkey, & Carskadon, 1994), or both wrists equally
active (J. J. van Hilten, Middelkoop,et 01., 1993). Recording activity every 30
seconds, J. J. van Hilten, Middelkoop, et 01. (1993) reported that when data for
the dominant wrist were submitted to the sleep-wake scoring algorithm devel-
oped for the nondominant wrist, and vice versa, agreement rates ranged from
93% to 99% across all 36 subjects.
Sleep-Onset Spectrum
The one point of consistent disagreement between wrist actigraphy and

PSG pertains to determination of sleep-onset latency (SOL). Some poor sleepers
can lie awake quietly for about an hour prior to the onset of EEG defined Stage 1
Sleep. Wrist actigraphy identifies sleep onset much earlier. This discrepancy in
SOL is fully understandable once one realizes that sleep onset is not a discrete
event but entails a sequence of physiological changes over an interval of time
that Ogilvie and Wilkinson (1988) and Ogilvie and Harsh (1994) refer to as the
sleep-onset period (SOP). Tryon (1991) prefers the term Sleep Onset Spectrum
(SOS) because it emphasizes that an orderly and predictable transitional se-
quence of events characterize the sleep-onset process. EEG Stage 1 sleep onset
was validated using the behavioral "gold standard" that people drop handheld
objects when they go to sleep because muscle tone decreases prior to EEG-
defined sleep onset (d. Blake, Gerard, & Kleitman, 1939; Perry & Goldwater,
538 Warren W. Tryon
1987; Snyder & Scott, 1972). The validational criteria for EEG Stage 1 sleep are
behavioral and can be used to correct wrist actigraphic SOL estimates. Ogilvie,
Wilkinson, and Allison (1989) instructed subjects to keep a 90-gram handheld
"deadman" switch closed while awake. Decreased muscle tone associated with
EEG Stage 1 sleep-onset reduced the subject's grip sufficiently to allow the
switch to open.
The ability to study sleep behaviorally under natural conditions is a most
welcome addition to geropsychology because sleep problems increase dramati-
cally as a result of normal and pathological aging (Bliwise, 1994b). To be able to
study sleep noninvasively under natural conditions rather than in a sleep labo-
ratory with an array of sensors attached to the head, eye, ear, nose, chest, and
legs is especially important for elderly subjects whose sleep is more easily dis-
turbed than that of younger subjects. Wrist actigraphy affords an opportunity
to better evaluate sleep variability because sleep can be studied for weeks at a
time if desired. The expense of a sleep laboratory typically restricts investiga-
tions to two nights with the first night's data being discarded because of well-
known first-night artifact. Van Hilten, Braat, and colleagues (1993) reported no
first-night effect associated with home wrist actigraphy. The scientific advan-
tages of wrist actigraphy for the longitudinal study of sleep and its variability
extend to subjects of all ages.
Sleep and Aging

Bliwise (1993, 1994a, 1994b) reviewed changes in sleep due to normal ag-
ing and dementia. Bliwise (1994b) defined normal sleep in the aged as what oc-
curs in persons over the age of 60 years. I confine myself to behavioral indices.
Aging is associated with increased nocturnal awakenings. Sleep onset is
delayed in older persons; this delay explains why they consume the prepon-
derance of sleep medications. Elderly women are greater users of sleep medica-
tions than are elderly men reflecting their more troubled sleep. Disease and
chronic illness compromise the sleep of elderly people. Excessive bedrest dis-
rupts the sleep-wake schedule of even young people. Curtailment of daytime
napping can improve nighttime sleep. Some elderly people fear dying in their
sleep and are therefore afraid to go to sleep. This fear is not unfounded as peo-
ple tend to be born and to die at night (Kryger, Roth, & Carskadon, 1994).
Women may experience more rapid sleep deterioration than men; this implies
greater dysregulation of sleep-wake cycles i:q. women than in men. Breathing ab-
normalities increase with age up to at least 60 years of age. These problems can
further compromise sleep. Forty-five percent of independently living persons
over the age of 65 experience periodic leg movements (PLMs) during sleep,
which can cause awakening.
'lUne (1968) obtained sleep charts from 240 subjects for 8 weeks. Twenty
men and 20 women represented six different age ranges from the 20s to the 70s.
The total sleep times for these age groups decreased slightly over the first four
age groups, increased slightly from age 60 to 70, and then decreased slightly af-
ter age 70.
Middelkoop and Kerkhof (1990) obtained non dominant wrist actigraphy
over two consecutive days from 14 older (mean age = 71 years; 5 women, 9
men) and 21 younger (mean age = 24 years; 12 women, 9 men) subjects. All sub-
jects were reportedly good sleepers. The only significant finding was that older
subjects slept longer (mean = 489 min, SD = 44 min) than younger subjects
(mean = 455 min, SD = 50 min) subjects.
Van Hilten, Braat, and colleagues (1993) used wrist actigraphy to evaluate
the sleep of 99 healthy subjects (43 men, 56 women) aged 50 to 98 years over 6
successive nights sleeping in their own beds. The only significant sex effect was
that women had more periods of immobility, defined as 1-min epochs of zero
activity, than men. Sleep indices were consistent over all 6 nights. No first-night
effect was observed like that associated with sleep laboratory study. Hence, no
adaptation period seems required. No significant age differences were reported.
Kripke, Ancoli-Israel, Klauber, and Wingard (1995) reported data on 355
adults aged 40 to 64 years who underwent 3 nights of home pulse oximetry and
wrist actigraphy (Actillume (tm)) recording. They found breathing disordered
sleep in 5.6% of Whites (n = 285), 15.9% of Hispanics (n = 44), and 16.7% of
Blacks (n = 12).
Kuo and colleagues (1995) obtained 6 nights of polysomnography from 22
women aged 59 to 79 years (mean = 68.1), and 8 men aged 63 to 78 years (mean
= 70.1). They reported significantly more movement time for men than women
due to a higher prevalence of sleep apnea and Periodic Limb Movements in
Sleep (PLMS), a movement disorder that disrupts sleep.
Thoman and colleagues (1993) stated that polysomnography is more prob-
lematic with older than younger persons because their sleep is more fragile and
more easily disrupted by attached electrodes (d. Bliwise, 1994a). Hence, they
developed a Home Monitoring System (HMS) consisting of a thin pressure-sen-
sitive mattress pad capable of measuring respiration and voluntary movements.
Four nights of motility records for 40 women aged 65 to 94 years (mean = 77.6)
were scored in 30-s epochs for Time-in-Bed, Sleep Latency, Sleep Period, Sleep,
Total Sleep Time, Longest Sustained Sleep Period, Wake After Sleep Onset, Fre-
quency of Waking, Respiratory Disturbance Index, and Periodic Leg Movements
while subjects slept in their own beds. No "first night" effect was found for any
variable. Reliability estimates ranged from .70 to .80. No significant correlations
with age emerged for any variable.
Sleep Disorders
Tryon (1991, pp. 149-195, 1996, 1997) has reviewed the applicability of
actigraphy to sleep disorders in general. The following material is focused on
the elderly.
Insomnia and Sleep Quality

Moran, Thompson, and Nies (1988) reviewed sleep disorders associated
with aging. Sleep latency, the time taken to fall asleep, remained constant but
sleep quality deteriorated with increasing age. Sleep quality deteriorates be-
cause the number of awakenings after sleep onset increase and the duration of
these awakenings increase with age, resulting in less satisfying sleep. Seriously
fragmented sleep is a sign of delirium in the elderly.
540 Warren W. Tryon
Pollak, Perlick, Linsner, Wenston, and Hsieh (1990) surveyed 1,855 com-
munity residents aged 65 to 98 years (mean = 75.4) and reinterviewed them at
6-month intervals over the next 3.5 years. During this time 309 respondents
were placed in nursing homes. Difficulty falling asleep and maintaining sleep,
and waking too early was significantly associated (X2 (3, N = 736) = 10.22, P
< .017) with nursing home placement.
Pollak, Ford, McGuire, Vaisman, and Zendell (1995) obtained 9 consecu-
tive days of non dominant-wrist actigraphy from 52 elder-caregivers and the per-
sons they were giving care to. The caregivers were younger (mean age = 63.5
years) than the elders they cared for (mean age = 78.4 years), but predominantly
female in both cases (54% female caregivers, 57% female elders). Results indi-
cated that the caregivers were more active during the day than the elders but
less active at night. Increased nocturnal activity on the part of elders probably
reflects their impaired sleep.
Most age-related changes in sleep and estimates of sleep disorders in the el-
derly, such as those just mentioned, have been obtained from clinical popula-
tions (Pollak, Perlick, & Linsner, 1992). These results may not generalize to
elderly persons who do not seek treatment for their sleep problems. Therefore,
Pollak et a1. (1992) interviewed 1,856 elderly residents residing in the Bronx, NY
(d. Pollak, Perlick, & Lisner 1986; Pollak et ai., 1990) and selected 31 insomni-
acs and 23 age- and gender-matched control subjects to wear a wrist actigraph
(PMS-8, Vitalog, Inc.) and keep a sleep diary for 14 consecutive nights. Results
revealed equivalent 24-hour activity levels with significantly different patterns.
However, when data above a specified threshold were analyzed, insomniacs
were found to be significantly less active than controls. Imposing the threshold
was equivalent to restricting data analysis from about 8:30 A.M. to almost 10:00
P.M. Insomniacs were found to be less active than controls during these times of
the day. From about 2:00 A.M. until 8:00 A.M. insomniacs became up to twice as
active as control subjects. The combined effect is that insomnia is associated
with a difference between activity lows and highs that is smaller than that in
normal control subjects. This represents a blunting of the circadian cycle.
Apnea
Svanborg and colleagues (1990) used a static-charge-sensitive bed (SCSB)
to monitor respiration and ear oximetry to monitor oxygen saturation in an ef-
fort to detect obstructive sleep apnea (OSAS) in 77 patients aged 17 to 68 years
(mean = 49 years) suspected of having obstructive sleep apnea syndrome. Ob-
structive apneas leave a special SCSB signature. Concurrent oxygen reduction
confirms that breathing halted or was significantly impaired when this signa-
ture occurred. Control subjects were 17 healthy nonhabitually snoring men and
women aged 15 to 58 years (mean = 36 years). Concurrent polysomnography
was used as the criterion measure. Results indicated that 55 of the 77 subjects
had OSAS. The SCSB plus oximetry detected all subjects with apnea: 100%
sensitivity. Seven additional false-positive cases were identified for a speci-
ficity of 67%. Hence, recording behavioral movements during sleep caused by
variations in respiration, along with ear oximetry, offer a cost-effective method
of screening for OSAS.
Restless Legs
Flemming, Clark, Wood, and Ramirez (1994) demonstrated that leg actigra-
phy can reliably detect polysomnography-defined PLMS. They initially vali-
dated leg actigraphy using 39 subjects (18 men, 21 women; mean age 45.0 years)
for whom 2 nights of data were collected as part of a larger polysomnography
PLMS study. Using 60-s recording epochs, they reported that activity counts of
30 or more following four epochs of less than 30 counts were associated with
arousal. They reported that ankle actigraphy correctly identified 87.7% of PSG-
defined PLMS with a false-negative rate of 3.1 % and a false-positive rate of
9.2%. The authors cross-validated their findings on 65 subjects (24 men, 41
women) of mean age 46.2 years for whom 1 night of data were available result-
ing in 89.7% correct identification with false-negative and false-positive rates
of 2.6% and 7.7%, respectively.
Massie, Daniels, and Juszynski (1995) used Flemming and colleagues,
(1994) ankle actigraphy methodology to measure PLMS in 14 healthy adults (7
men, 7 women) aged 23 to 56 years (mean = 35.2) for 3 consecutive nights while
subjects slept in their own beds. No "first night" effect was found. The authors
reported that 65.6% of all leg movements were below the 3D-count threshold as-
sociated with arousal indicating that about one third of leg movements pro-
duced arousal.
Trenkwalder and colleagues (1995) evaluated restless legs syndrome using
actigraphy and polysomnography in 32 White men and women aged 29 to 73
years. Actigraphic data revealed a time course similar to that of polysomnogra-
phy in measuring response to L-dopa treatment.
Kazenwadel and colleagues (1995) described a new actigraphic method for
detecting PLMs using high-resolution, high-speed recording. An accelerometer
placed on the top of the foot is connected to a recording unit that digitizes the
amplitude of movements on a 0 to 253 scale and integrates and records move-
ment over each tenth of a second (10 Hz). Blocking the data into half-second
epochs, the authors were able to accurately monitor PLMs in 30 subjects aged
29 to 74 years as validated by standard electromyograpy.
Arthritis
Lavie, Epstein, and colleagues (1992) investigated the effect of rheumatoid
arthritis (RA) on sleep using 4 consecutive nights of i-min epoch wrist activity.
The experimental group consisted of 13 women (mean age = 55.8 years) outpa-
tients diagnosed as having active classical or definite RA. Twelve healthy
women (mean age = 54.6 years) served as normal controls. A third group of 9
women (mean age = 35.5 years) with chronic back pain were also studied. The
results revealed that the sleep of patients with RA was clearly more fragmented
than that of normal controls. The sleep of persons with chronic back pain was
also more fragmented than the sleep of control subjects but not as severely frag-
mented as patients with RA. After controlling for age, significant between-
group differences were obtained for sleep duration, sleep efficiency, mean
activity level, and longest interval of continuous sleep. The clinical variable
most closely associated with actigraphic recordings was degree of evening pain
542 Warren W. Tryon
which was significantly correlated with activity during sleep (r(ll) = .62, P <
.03), with sleep efficiency (r(11) =-.66, P < .03), and with percentage of epochs
of zero activity (r(ll) =-.66, P < .01). Pain during sleep was significantly corre-
lated with the percentage of epochs of zero activity (r(ll) =-.68, P < .01).
Parkinson's Disease
Van Hilten and colleagues (1994) used 6 successive nights of wrist actigra-
phy to evaluate the sleep of 89 nondepressive patients (50 men, 34 women)
with ideopathic Parkinson's disease (PD) and 83 age-matched (mean = 66.7
years) healthy controls (38 men, 45 women). Results revealed that patients with
PD had a significantly higher activity level than controls. Those PD patients
with sleep complaints had a significantly higher movement index defined as
the number of l-min epochs with more than zero activity counts. The mean im-
mobility index, number of epochs of zero activity, did not differentiate the two
groups. Activity level (r(81)= .458, p < .001) was significantly correlated with
levodopa use. In the 34 subjects not receiving levodopa, activity level was sig-
nificantly correlated with disease severity (r(32)= .510, p < .002). Resting tremor
did not influence the activity readings taken during sleep because tremor dis-
appears during sleep.
CIRCADIAN RHYTHMS
The previous sections have focused either on daytime or nighttime activity.

This section is comprehensive in that it is concerned with 24-hour activity sam-
ples. Modern actigraphy makes collecting these data very simple. Tryon and
Williams (1996) describe a small, lightweight device capable of recording data
every minute of the day and night for 22 days before memory is filled. Down-
loading and reprogramming takes just a few minutes and enables another data
collection cycle. This process can be repeated indefinitely to obtain very com-
prehensive rest(sleep)-wake data. The subject need only wear the device. Non-
compliance is easily detected by a flat line where minimal movement should be
present.
Most biological functions are not constant but vary throughout the day and
night (Kryger et aI., 1994). Temperature and activity are the two most frequently
studied indices of circadian regulation in the laboratory. More research has
been conducted on activity than on temperature because it is easier to continu-
ously measure revolutions of a rodent activity wheel than it is to obtain rectal
temperatures at fixed intervals. Small computerized wrist- and waist-worn acti-
graphs methodologically extend the activity literature to humans.
Circadian rhythms are poorly developed at birth but become much better
defined during the first month or two of life (Weinert, Sitka, Minors, & Water-
house, 1994). The newborn infant sleeps much of the time. A transition period
of sleep and wake during some part of every hour is followed by consolidating
sleep into a single period and wake into another period resulting in the normal
sleep-wake circadian cycle by the end of the first year oflife (Sadeh, 1994). Psy-
chological circadian rhythms for subjective activation, mood, and performance
efficiency also develop (Monk, 1994). Sleep remains consolidated into a single
period in healthy adults. Normal aging fractionates nocturnal sleep by inter-
spersing periods of wakefulness (Bliwise, 1993, 1994b). Napping during the day
further fractionates the circadian rhythm.
The biological clock seems to be located in the suprachiasmatic nuclei
(SCN) of the anterior hypothalamus (Bliwise, 1994b; Harrington, Rusak, &
Mistleberger, 1994; Kryger et aI., 1994). Mistleberger and Rusak (1994) indi-
cated that the human biological sleep-wake clock has a natural period of about
25 hours. This means that people naturally go to sleep about an hour later each
day if isolated from all temporal cues, called zeitgebers, that entrain the circa-
dian rhythm to a 24-hour solar cycle. Light is a powerful zeitgeber and can be
used to phase shift circadian rhythms (Mistleberger & Rusak, 1994). Feeding an-
imals once per day causes activity to peak at feeding time (Mistleberger &
Rusak, 1994). Ablating the SCN in the rat produces ultradian sleep-wake cycles
with a periodicity of 3 to 4 hours (Harrington et aI., 1994). The human SCN de-
creases in size with age especially beyond 80 years of age (Bliwise, 1994b).
Aging Effects
The effects of aging on circadian rhythm were studied by Lieberman, Wurt-

man, and Teicher (1989) using wrist actigraphy in 17 men aged 65 to 94 years
(mean = 71.4 years) and 23 women aged 65 to 85 years (mean = 74.6 years). All
were in good health and not institutionalized. A young comparison group con-
sisted of 15 men aged 21 to 35 years (mean = 27.7 years) and 14 women aged
19 to 31 years (mean = 24.5 years). Activity was measured over 15-min epochs
for 3 full days while subjects temporarily resided at the MIT Clinical Research
Center to control for living conditions. A wide range of recreational opportuni-
ties were available. The results revealed that a consolidated sleep-wake circa-
dian cycle extended into old age, the primary difference being that older
persons were more active in the early morning than the young subjects. How-
ever, young men were as active as older men by midmorning and were more ac-
tive by evening. Young women were less active than older women except
during the evening, when they were slightly more active. Women were signifi-
cantly less active than men. The most prominent effect of age was to move the
time of peak activity from 1513 hours to 1326 hours. This temporal adjustment
is referred to as a phase advance.
Renfrew, Pettigrew, and Rapoport (1987) used nondominant wrist actigra-
phy to study the circadian rhythm of 43 men aged 21 to 83 years (mean = 51.9
years) for 9 consecutive days. Three age groups were constructed. Subjects aged
21 to 39 years were classified as young (n = 13); those 40 to 59 years were clas-
sified as middle-aged (n = 12); and those 60 to 83 years old were classified as
old (n = 18). Circadian amplitude refers to the difference between periods of
highest and lowest activity. The stability of the circadian cycle is thought to be
directly proportional to its amplitude (Van Goal & Mirmiran, 1986; Wever,
1979). Results revealed that the young subjects were least active at night and
most active during the day (i.e., they demonstrated the greatest difference be-
tween low and high activity periods: they had the greatest circadian amplitude).
544 Warren W. Tryon
The middle-aged subjects were more active during the night and less active dur-
ing the day than the other two groups. They had the smallest difference be-
tween low and high activity and therefore the lowest circadian amplitude. The
old group was intermediate between the young and middle-aged subjects. Com-
paring just the old and the young, it was found that older subjects were more ac-
tive at night and less active during the day than young subjects on both
weekdays and weekends. The younger subjects began their active phase ap-
proximately 1 hour later on the weekends than during the weekdays. Older sub-
jects kept the same schedule throughout the week.
The circadian cycle remains largely intact until late life, when it begins to
fragment. Sleep problems during the night produce daytime sleepiness which
leads to napping, thereby breaking the consolidated sleep-wake cycle into two
or more sleep-wake cycles per day. D. Jacobs, Ancoli-Israel, Parker, and Kripke
(1989) used wrist actigraphy to study the sleep-activity patterns of 19 elderly
nursing home residents aged 71 to 99 years (mean = 84.4 years) for a single 24-
hour period using 1-min recording epochs. Results indicated an average of
11.73 hours of sleep (SD = 3.59 hr). Sleep was distributed, on average, over
everyone of the 24 hours. The mean number of minutes asleep was approxi-
mately 15 or more of each hour. Conversely, there was no hour during which
subjects were awake all of the time. Only 6 ofthe 19 subjects experienced even
a single hour of consolidated sleep and only 3 subjects experienced 2 hours of
consolidated sleep. The circadian sleep-wake cycle for these residents resem-
bles that of the neonate and probably increases confusion regarding date and
time of day. Some part of this deterioration is undoubtedly due to the effects of
aging on the biological clock, SCN of the hypothalamus.
However, Witting, Kwa, Eikelenboom, Mirmiran, and Swaab (1990) used
actigraphs to monitored rest-activity cycles in 13 elderly subjects (2 men, 11
women, aged 71 to 85 years), and 6 young control subjects (4 men, 2 women,
aged 29 to 55 years) using wrist actigraphy for 90 to 168 hours. They reported
that the rest-activity cycle of the two groups was comparable. Low statistical
power may well be responsible for the lack of significant differences.
Dementia
Van Someren, Mirmiran, and Swaab (1993) conclude that deterioration of

the biological clock results in a dampened circadian rhythm thereby causing
several age-related problems with sleep and wakefulness. Aharon-Peretz and
colleagues (1991) used actigraphs to compare the circadian rhythms of 10
patients with multi-infarct dementia (mean age = 75.6), 15 patients with
Alzheimer's dementia (mean age = 72.8), and 11 age-matched healthy volun-
teers (mean age = 69.0) for 8 consecutive days. Analysis of variance revealed
that Alzheimer and control subjects were not significantly different on any vari-
ables. However, multi-infarct dementia subjects were significantly and sub-
stantially more active and had lower sleep efficiency (minutes asleep/minutes
in bed) than Alzheimer's or control subjects.
Fishbein, Ferris, and Reisberg (1995) reported a progressive circadian
rhythm decline in patients with Alzheimer's dementia (AD). They used wrist
actigraphy to monitor the sleep-wake cycles of 15 reliably diagnosed patients
with AD (mild to severe) and 6 healthy age-matched controls for 12 consecutive

days. Spectral analysis revealed that four activity cycles per 24 hours charac-
terized the behavior of the healthy control subjects with little nocturnal activ-
ity. Five to eight activity cycles characterized the AD patients. Hence, dementia
appears to increase the number of activity cycles per day. Moreover, these cy-
cles were phase shifted to an earlier clock time. A progressive increase in noc-
turnal activity was observed as dementia severity increased from mild to severe.
Sanford (1975) identified night wandering as an important factor leading to the
institutionalization of elderly dependents.
Depression
Raoux and colleagues (1994) used 24-hour nondominant wrist actigraphy

to evaluate 26 depressed inpatients before and after 4 weeks of chemotherapy.
Pretreatment included two 24-hour periods before drug treatment began. Post-
treatment included the final three 24-hour periods prior to discharge. Activity
level improved markedly at posttreatment. No difference was found between
morning and afternoon activity. Circadian amplitude increased significantly as
a result of treatment, largely because of increased diurnal activity.
Sleep
Bliwise (1994a) indicated that very few studies of sleep in well-docu-

mented cases of AD exist. Lower sleep efficiency and greater frequency of
arousal and awakening seemed to occur in demented compared to control sub-
jects. The effect size appeared to closely parallel the degree of dementia.
Differential diagnosis of dementia and depression is challenging but actig-
raphy may be informative in this regard. Bliwise (1994a) reported that de-
pressed subjects experienced greater sleep disturbances than did demented
subjects. Nocturnal actigraphy may be able to discriminate depressed from de-
mented subjects on the basis ofthe degree of sleep disruption. The main confu-
sion on the basis of sleep data alone would be between severely demented and
depressed subjects but a differential diagnosis is relatively easy in these cases
using other information. The important contribution of sleep data is that they
may help distinguish depression from mild dementia.
Pollak and colleagues (1995) obtained 9 consecutive days of wrist actigra-
phy using 30-s recording epochs on 17 demented and 52 nondemented elders
and their respective caregivers. The rest-activity cycles of the demented sub-
jects were phase shifted more than 4 hours earlier than for the nondemented
subjects. The rest-activity cycle for the caregivers living with the demented sub-
jects was phase shifted approximately 3 hours earlier than for the caregivers liv-
ing with the nondemented subjects. Given that normal aging tends to phase
advance the circadian cycle (Lieberman et aJ., 1989; Renfrew et al., 1987), de-
mentia appears to emulate advanced aging.
Witting and colleagues (1990) monitored rest-activity cycles in 12
Alzheimer's disease patients (2 men, 10 women, aged 71 to 86 years), 13 elderly
control subjects (2 men, 11 women, aged 71 to 85 years), and 6 young control
546 Warren W. Tryon
subjects (4 men, 2 women, aged 29 to 55 years) using wrist actigraphy for 90 to

168 hours. They reported that the rest-activity cycle of the demented subjects
was disturbed in direct proportion to the severity of the dementia.
Dementia is associated with personality changes including agitated behav-
iors (Eisendorfer et al., 1992) and sleep-wake disorders (Reisberg et al., 1987;
Teri et a1., 1988; Winograd & Jarvik, 1986). These behaviors are an important
contributing cause of caregiver burnout leading to institutionalization of the
care receiver (Reisberg, et a1., 1987).
Satlin and colleagues (1991) studied the locomotor activity of 11 demented
men and 8 demented women, aged 59 to 92 years (mean =72.6 years). Eight of
19 subjects were clinically defined as "pacers." Eight healthy volunteers (5
men, 3 women) aged 67 to 75 years served as control subjects. Activity was
measured using 5-min epochs over 48 to 72 hours with waist (vest)-worn acti-
graphs (Ambulatory Monitoring, Inc., Ardsley, NY). The results showed that
pacers were 66% more active than controls whereas the remaining demented
subjects were 39% less active than control subjects. Pacers' nocturnal activity
was approximately four times greater than that of control subjects. This finding
is similar to that reported by Teicher and colleagues (1988) for depressed geri-
atric patients.
The stability of the circadian cycle is thought to be directly proportional to
its amplitude (Van Gool & Mirmiran, 1986; Wever, 1979). The authors evaluated
circadian strength by dividing the circadian amplitude by the daily average
(mesor). Although pacers had a 22% lower relative amplitude than controls, this
difference was not statistically significant because of the small sample size. The
acrophase, time of maximum activity, was delayed, occurring later in the day, by
126 min, 2 hr and 10 min, (3:14 P.M.) relative to control subjects (1.08 P.M.).
Ancoli-Israel, Klauber, Butters, Parker, and Kripke (1991) used wrist actig-
raphy and Respitrace/Medilog respiration recordings in 152 women and 83
men residing in a skilled nursing facility to show that dementia and sleep ap-
nea are related. All residents with severe sleep apnea were also found to be se-
verely demented. Apnea disrupts sleep and deprives one of oxygen which may
exacerbate the symptoms of dementia.
Lavie, Aharon-Peretz, and colleagues (1992) compared the sleep of 10 nor-
mal controls (6 women, 4 men) aged 71.37 years on average with 10 patients (2
women, 8 men) with multi-infarct dementia of average age 76.03 years, and 12
patients (9 women, 3 men) of average age 75.06 years using four periods of 5 to
7 days of wrist actigraphy. The results indicated that only the multi-infarct de-
mentia group showed evidence of disturbed sleep. The authors noted that the
Alzheimer's patients suffered only mild dementia and that sleep disruption
may occur only as dementia worsens.
Sundowning
Psychopathology disturbs normal circadian rhythm. Switches from de-

pression to mania can drastically shorten or eliminate the sleep period at the
point of transition and dramatically increase activity level (Bunney et a1., 1977;
Thyon, 1991, pp. 65-82). Thyon (1997) discusses the role of activity in DSM-W
disorders. Some patients with Alzheimer's disease evidence "sundowning."

This is a syndrome of confusion and agitation occurring in the late afternoon
and early evening (Evans, 1987). Bliwise (1994a) reports that the most difficult
part of sundowning for the caregiver is that the patient is active and noisy at
night when the caretaker is trying to sleep. Sundowning is, therefore, one of the
most common causes of institutionalization of demented geriatric patients.
The fact that sundowning symptoms occur at approximately the same time
each day led Satlin, Volicer, Ross, Herz, and Campbell (1992) to conclude that
they reflected a circadian disorder. Accordingly, the authors sought to alleviate
the behavioral and sleep disturbances of patients with Alzheimer's disease us-
ing properly timed bright light. Subjects were 10 inpatients (9 men, 1 woman)
aged 70.1 years on average. Most began yelling or pacing between 2 and 4 P.M.
Most patients had sleep disorders and frequently napped during the day. Ac-
tivity was measured with a waist (vest)-worn actigraph for 48 hours during the
first and third week of the study. From 7 to 9 P.M. during the intervening week,
subjects received 2 hours of bright (1500 to 2000 lux) light while seated in a
geri-chair. Clinical ratings of sleep and wakefulness improved (decreased) sig-
nificantly from 6.2 pretreatment to 3.0 during treatment to 2.3 posttreatment.
The percentage oftotal daily (24-hour) activity occurring between 1:00 P.M. and
7:00 A.M. decreased significantly during treatment from 18.4% to 11.6% but
then increased to 17.1 % after treatment ended, indicating that light has a tem-
porary effect on nocturnal activity. The severity of sundowning correlated r(8)
= .74, P < .01 with the relative rest-activity amplitude calculated as the differ-
ence between peak and average activity. The degree of improvement was sig-
nificantly correlated with initial sun downing score (r(8) = .65, P < .01) during
treatment and during posttreatment (r(8) = .77, P < .004). The authors report
that two Japanese studies also indicate that bright light is an effective treatment
for Alzheimer's disease and multi-infarct dementia. Czeisler and colleagues
(1986) report that properly timed bright light can phase shift the circadian cy-
cle and augment its amplitude.
Teicher and colleagues (1988) used actigraphs to measure activity levels and
circadian rhythms for 48 to 64 hours in eight hospitalized geriatric unipolar de-
pressed patients and eight healthy elderly controls in a similar environment. The
peak activity of depressed patients was at 3:54 P.M. versus 1:51 P.M. for control sub-
jects (t(14) = 4.67, P < .001). The nearly 4:00 P.M. time of peak activity for depressed
patients suggests that they could be mistakenly diagnosed as sundowning.
CONCLUSIONS/SUMMARY
Geropsychologists have at least five reasons for interest in physical activity.

A conclusion is associated with each of these reasons.
1. Activity is a truly life-span developmental personality variable. Stable

individual differences in activity level begin prenatally. All theorists and in-
vestigators recognize activity level as a primary dimension of infant tempera-
ment. Such unanimous theoretical agreement and such consistent empirical
support is extremely rare in psychology. Activity level appears to reduce to a
548 Warren W. Tryon
facet of Introversion/Extroversion in adulthood primarily because it is repre-

sented by so few items on adult personality inventories. It is a well-known psy-
chometric fact that reducing the number of items pertaining to a construct
generally reduces the prominence of that construct in factor analyses. Ability to
ambulate and choice of an active lifestyle assume ever greater importance as an
individual difference or personality factor with increasing age. Chronic physi-
cal illness moderates the expression of personality factors with increasing age.
We therefore conclude that it is appropriate for geropsychologists to examine
the roots of activity differences in the elderly by obtaining naturalistic activity
measurements from younger cohorts.
2. Evidence was reviewed associating activity level and physical health.
The term "hypokinetic disease" coined by Kraus and Raab (1961) merits addi-
tional consideration at this time given that our population is rapidly aging and
that the annual cost of medical care for many of us increases as we reach old
age. O'Brien and Vertinsky's (1991) estimation that about 50% of what we cur-
rently accept as aging results from hypokinesis indicates that aging can be re-
duced in clinically meaningful ways. People of all ages benefit from avoiding a
sedentary lifestyle. The largest risk reduction of death from all causes occurs
when one moves out of the least activity category thereby demonstrating the
value of even modest activity increases. We therefore conclude that it would be
useful for geropsychologists to further investigate the health risks and benefits
associated with objectively measured activity levels in elderly persons.
Another important contribution of actigraphy to behavioral medicine is
that it may be used to quantify recovery from illness or surgery. Surgical pa-
tients have nearly zero activity levels immediately after surgery and are able to
ambulate and care for themselves to a degree at discharge. Convalescence is
normally associated with further activity increases. We therefore conclude that
the rate and extent of return to preoperative activity level can be used as an ob-
jective marker of recovery from surgery and important illness.
3. Evidence was reviewed showing that activity apparently improves men-
tal health by reducing depression and anxiety. Evidence was reviewed demon-
strating that activity improves cognitive functioning, perhaps through increased
blood flow. The paucity of research in this area leads us to conclude that it is
appropriate for geropsychologists to further investigate the mental health bene-
fits associated with increased activity in the elderly.
4. Nocturnal wandering while caretakers attempt to sleep is a major reason
for institutionalization of the care receiver. Actigraphy can objectively document
the extent to which nocturnal wandering occurs. Sleep disorders become in-
creasingly common with advanced age. The possibility of longitudinal studies of
sleep in the person's own home through wrist actigraphy offers geropsychologists
new opportunities to learn more about normal sleep and developmental changes
in sleep across the life span. The Sleep-Onset Spectrum (SOS) was described and
the gradual and continuous process of going to sleep was emphasized. Poor sleep-
ers seem to take longer to complete the sleep-onset process and older persons ap-
pear to become poorer sleepers. Contributions of actigraphy in the assessment of
sleep disorders was reviewed. Hence, we conclude that geropsychologists have a
clear interest in learning more about the similarities and differences of the sleep-
onset process in older healthy persons compared to younger poor sleepers and in
using actigraphy to obtain the necessary longitudinal and naturalistic behavioral

samples.
5. Advanced age is associated with deterioration in our biological clocks
thereby producing changes in our circadian rhythm. Dementia exacerbates this
deterioration. Uniform agreement exists that activity level is the second most
prominent index of circadian rhythm. Core body temperature is the indicator of
choice but is much more difficult to obtain over days, weeks, and months than
actigraphic data which can now be provided every minute of the day and night
for 22 consecutive days prior to downloading the data and beginning again. We
therefore conclude that geropsychologists can advance our understanding of
circadian rhythms by obtaining 2-week or longer activity records from elderly
persons as they live in their natural environment.
6. Activity as a theoretical construct has long been of interest to psycholo-
gists. Empirical methods of obtaining activity data have largely been confined
to self-report via questionnaire, diary, or log. These data have questionable re-
liability and validity primarily because they are limited by memory and com-
pliance factors and subjects' willingness to be honest with themselves and with
others. Moreover. people cannot be expected to quantify physical forces as ac-
curately as instruments can. The technology of actigraphy has matured consid-
erably (cf. Tryon & Williams, 1996) and now is technically feasible and cost
effective. We therefore conclude that future investigators should use some type
of instrument when investigating activity.
REFERENCES
Ades. P. A., Waldmann, M. L., & Gillespie, C. (1995). A controlled trial of exercise training in older
coronary patients. Journal of Gerontology: Medical Sciences, 50A, M7-Mll.
Aharon-Peretz, J., Masiah, A., Pillar, T., Epstein, R., Tzischinsky, 0., & Lavie, P. (1991). Sleep-wake cy-
cles in multi-infarct dementia and dementia of the Alzheimer type. Neurology, 41, 1616-1619.
Ancoli-Israel. S., Klauber, M. R., Butters, N., Parker, L., & Kripke. D. F. (1991). Dementia in institu-
tionalized elderly: Relation to sleep apnea. Journal of the American Geriatric Society, 39,
258-263.
Bierman, E. L. (1978). Atherosclerosis and aging. Federal Proceedings, 37, 2832-2836.
Birrell, P. C. (1983). Behavioral. subjective, and electroencephalographic indices of sleep onset la-
tency and sleep duration. Journal of Behavioral Assessment, 5, 179-190.
Blair, S. N., Kohl. H. w., Paffenbarger, R. 5., Jr., Clark, D. G., Cooper, K. H., & Gibbons, L. W. (1989).
Physical fitness and all-cause mortality: A prospective study of healthy men and women. Jour-
nal of the American Medical Association, 262, 2395-2401.
Blake, H., Gerard, R. W., & Kleitman, N. (1939). Factors influencing brain potentials during sleep.
Journal of Neurophysiology, 2, 48-60.
Bliwise, D. L. (1993). Sleep in normal aging and dementia. Sleep, 16,40-81.
Bliwise, D. 1. (1994a). Dementia. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and
practice of sleep medicine (2nd ed., pp. 790-800). Philadelphia: W. B. Saunders.
Bliwise, D. L. (1994b). Normal Aging. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles
and practice of sleep medicine (2nd ed., pp. 26-39). Philadelphia: W. B. Saunders.
Blumenthal, J. A., Emery, C. F., Madden, D. J., George, L. K., Coleman, R. E., Riddle, M. W., McKee,
D. C., & Williams, R. S. (1989). Cardiovascular and behavioral effects of aerobic exercise train-
ing in healthy older men and women. Journal of Gerontology: Medical Sciences, 44,
M147-M157.
Bonato, R. A., & Ogilvie, R. D. (1989). A home evaluation of a behavioral response measure of
sleep/wakefulness. Perceptual and Motor Skills, 68, 87-96.
550 Warren W. Tryon
Bortz W. M .• II. (1982). Disuse and aging. Journal of the American Medical Association. 248.
1203-1208.
Bouchard. C.• Shepard. R. J.• Stephens. T.• Sutton. J. R.• & McPherson. B. D. (1990). Exercise, fitness
and health. Champaign. IL: Human Kinetics.
Bunney. W. E.. Jr.• Wehr. T. R.. Gillin. J. C.• Post. R. M.. Goodwin. F. K.. & van Kammen. D. P. (1977).
The switch process in manic-depressive psychosis. Annals of Internal Medicine. 87. 319-335.
Burnside.!. M. (1978). Working with the elderly. North Scituate. MA: Duxbury.
Buss. A. H. & Plomin. R. (1984). Temperament: Early developing personality traits. Hillsdale. N.J.:
Erlbaum.
Carskadon. M. A .. Dement. W. C.. Mitler. M. M.• Guilleminault. C.• Zarcone. V. P.• & Spiegel, R.
(1976). Self-reports versus sleep laboratory findings in 122 drug-free subjects with complaints
of chronic insomnia. American Journal of Psychiatry, 133. 1382-1388.
Clarkson-Smith. L.. & Hartley. A. A. (1989). Relationships between physical exercise and cognitive
abilities in older adults. Psychology and Aging. 4, 183-189.
Colvin. R. H .• & Olson. S. B. (1983). A descriptive analysis of men and women who have lost sig-
nificant weight and are highly successful at maintaining the loss. Addictive Behaviors, 8.
287-295.
Costa. P. T.• Jr. & McCrae. R. R. (1980). Still stable after all these years: Personality as a key to some
issues in adulthood and old age. In. P. B. Baltes & a. G. Brim (Eds.). Life-span development
and behavior (pp. 65-102). New York: Academic.
Costa. P. T.• Jr. & McCrae. R. R. (1992). Revised NED Personality Inventory (NED PI-R) and NED Five-
Factor Inventory (NED-FFI): Professional manual. Odessa. FL: Psychological Assessment Re-
sources.
Costa. P. T.• Jr.• & McCrae. R. R. (1994). Stability and change in personality from adolescence
through adulthood. In C. F. Halverson. Jr.• G. A. Kohnstamm. & R. P. Martin (Eds.). The devel-
oping structure of temperament and personality from infancy to adulthood (pp. 139-150).
Hillsdale. NJ: Erlbaum.
Cunningham. D. A.• Rechnitzer. P. A .• Howard. J. H .• & Donner. A. P. (1987). Exercise training of men
at retirement: A clinical trial. Journals of Gerontology. 42, 17-23.
Czeisler. C. A .• Allan. J. S .• Strogatz. S. H .• Ronda. J. M .• Sanchez. R.• Rios. C. D.• Freitag. W. 0 ..
Richardson. G. S .• & Kronauer. R. E. (1986). Bright light resets the human circadian pacemaker
independent ofthe timing ofthe sleep-wake cycle. Science. 233. 667-671.
Davidson. M. B. (1979). The effect of aging on carbohydrate metabolism: A review of the English lit-
erature and a practical approach to the diagnosis of diabetes mellitus in the elderly. Metabo-
lism. 28, 688-705.
deVries. H. A. (1983). Physiology of exercise and aging. In D. S. Woodruff & J. E. Birren (Eds.). Ag-
ing (2nd ed.• pp. 285-304). New York: Van Nostrand.
Dishman. R. K. (1990). Determinants of participation in physical activity. In C. Bouchard. R. J..
Shephard. T. Stephens. J. R. Sutton. & B. D. McPherson (Eds.). Exercise. fitness and health (pp.
75-102). Champaign. 11: Human Kinetics.
Dishman. R. K. (1991). Increasing and maintaining exercise and physical activity. Behavior Ther-
apy, 22, 345-378.
Doyne. E. J.. Chambless. D. L.• & Beutler. L. E. (1983). Aerobic exercise as a treatment for depression
in women. Behavior Therapy, 14.434-440.
Dustman. R. E.• Ruhling. R. 0 .. Russell. E. M .• Shearer. D. E.• Bonekat. H. W.• Shigeoka. J. W.• Wood.
J. S .• & Bradford. D. C. (1984). Aerobic exercise training and improved neuropsychological
function of older individuals. Neurobiology of Aging. 5. 35-42.
Eaton. W. 0 .. & Saudino. K. J. (1992). Prenatal activity level as a temperament dimension? Individ-
ual differences and developmental functions in fetal movement. Infant Behavior and Devel-
opment, 15.57-70.
Eisendorfer. C.• Cohen. D.• Paveza. G. J.• Ashford. J. W.• Luchins. D. J.. Gorelick. P. B.• Hirschman.
R. S .• Freels. S. A .• Levy. P. S .• Semla. T. P.• & Shaw. H. A. (1992). An empirical evaluation of
the Global Deterioration Scale for staging Alzheimer's disease. American Journal of Psychia-
try, 140, 190-194.
Ensberg. M. D.• Paletta. M. J.. Galecki. A. T.• Dacko. C. L.• & Fries. B. E. (1993). identifying elderly
patients for early discharge after hospitalization for hip fracture. Journal of Gerontology: Med-
ical Sciences, 48, M187-M195.
Espie. C. A.. Lindsay. W. R.. & Espie, 1. C. (1989). Use of the sleep assessment device (Kelley and
Lichstein, 1980) to validate insomniacs' self-report of sleep pattern. Journal of Psychopathol-
ogy and Behavioral Assessment. 11,71-79.
Evans. 1. K. (1987). Sundown syndrome in institutionalized elderly. Journal of the American Geri-
atric Society, 35, 101-108.
Fillingim. R. B., & Blumenthal. J. A. (1993). Psychological effects of exercise among the elderly. In
P. Seraganian (Ed.). Exercise psychology: The influence of physical exercise on psychological
processes (pp. 237-253). New York: Wiley.
Fishbein, W., Ferris. S .. & Reisberg. B. (1995). Progressive circadian rhythm decline in Alzheimer's
disease. Sleep Research, 24, 519.
Fleming. J.• Clark. C ..Wood, C.• & Ramirez, C. (1994). Leg actigraphy reliably detects Periodic Limb
Movements during sleep. Sleep Research, 23, 437.
Folkins. C. H., & Sime. W. E. (1981). Physical fitness training and mental health. American Psy-
chologist, 36, 373-389.
Fox S. M .. III, Naughton. J. P.• & Haskell. W. 1. (1971). Physical activity and the prevention of coro-
nary heart disease. Annals of Clinical Research, 3, 404-432.
Franklin, J. (1981). The measurement of sleep onset latency in insomnia. Behaviour Research and
Therapy, 19,547-549.
Fremont, J., & Craighead, 1. W. (1984). Aerobic exercise and cognitive therapy for mild/moderate
depression. Presented at the Association for Advancement of Behavior Therapy. Philadelphia.
Gerety. M. B., Mulrow, C. D., Tuley, M. R.. Hazuda. H. P.. Lichtenstein. M. J., Bohannon, R.. Katen,
D. N .. O'Neil. M. G .. & Gorton, A. (1993). Development and validation of a physical perfor-
mance instrument for the functionally impaired elderly: The physical disability index (PDI).
Journal of Gerontology: Medical Sciences, 48, M33-M38.
Gibson. G. E.. & Peterson. C. (1982). Biochemical and behavioral parallels in aging and hypoxia. In
E. Giacobini. G. Filogamo, G. Giacobini, & A. Vernadakis (Eds.), The aging brain: Cellular and
molecular mechanisms of aging in the nervous system (pp. 107-122). New York: Raven.
Goldsmith. H. H .• Buss. A. H .. Plomin. R.. Rothbart, M. K .• Thomas, A., Chess, S .. Hinde, R. A., &
McCall, R. B. (1987). Roundtable: What is temperament? Four approaches. Child Develop-
ment, 58, 505-529.
Goodrick, C. L. (1980). Effects of long-term voluntary wheel exercise on male and female Wistar
rats. Gerontology, 26, 22-33.
Granada, A. M.. & Hammack. J. T. (1961). Operant behavior during sleep. Science, 133, 1485-1486.
Greist, J. H. (1984). Exercise in the treatment of depression. Coping with mental stress: The poten-
tial and limits of exercise intervention. Washington. DC: NIMH Workshop.
Greist, J. H .. Klein. M. H .. Eischens, R. R., Faris. J., Gurman, A. S .. & Morgan. W. P. (1979). Running
as treatment for depression. Comprehensive Psychiatry, 20, 41-54.
Gueldner, S. H .. & Spradley. J. (1988). Outdoor walking lowers fatigue. Journal of Gerontological
Nursing, 14,6-12.
Guralnik. J. M .. & Simonsick, E. M. (1993). Physical disability in older Americans. Journals of
Guralnik, J. M., Simonsick, E. M., Ferrucci, L.• Glynn, R. J., Berkman. 1. F., Blazer, D. G., Scherr,
P. A., & Wallace, R. B. (1994). A short physical performance battery assessing lower extremity
function: Association with self-reported disability and prediction of mortality and nursing
home admission. Journal of Gerontology: Medical Sciences, 49, M85-M94.
Harrington, M. E.. Rusak, B.• & Mistleberger, R. E. (1994). Anatomy and physiology of the mam-
malian circadian system. In M. H. Kryger, T. Roth. & W. C. Dement (Eds.), Principles and prac-
tice of sleep medicine (2nd ed., pp. 286-300). Philadelphia: Saunders.
Haskell. W. 1. (1985). Physical activity and health: Need to define the required stimulus. American
Journal of Cardiology, 55, 4D-9D.
Hill. R. D.• Storandt. M., & Malley. M. (1993). The impact oflong-term exercise training on psy-
chological function in older adults. Journal of Gerontology: Psychological Sciences, 48,
P12-P17.
Hoiberg. A .• Bernard. S., Watten. R. H.• & Caine. C. (1984). Correlates of weight loss in treatment and
at follow-up. International Journal of Obesity, 8,457-465.
Hol!oszy, J. O. (1993). Exercise increases average longevity of female rats despite increased food in-
take and no growth retardation. Journal of Gerontology: Biological Sciences, 48, B97-B100.
552 Warren W. Tryon
Holloszy, J. 0., & Schechtman, K. B. (1991). Interaction between exercise and food restriction: Ef-
fects on longevity of male rats. Journal of Applied Physiology, 70, 1529-1535.
Holloszy, J. 0., Smith, E. K., Vining, M., & Adams, S. A. (1985). Effect of voluntary exercise on
longevity ofrats. Journal of Applied Physiology, 59, 826-831.
Hultsch, D. F., Hammer, M., & Small, B. J. (1993). Age differences in cognitive performance in later
life: Relationships to self-reported health and activity life style. Journal of Gerontology: Psy-
chological Sciences, 48, Pl-Pl1.
Jacobs, B. L. (1994). Serotonin. motor activity and depression-related disorders. American Scientist,
82, 456-463.
Jacobs, B. 1., & Fornal, C. A. (1993). 5-HT and motor control: A hypothesis. Trends in Neuroscience,
16,346-352.
Jacobs, D., Ancoli-Israel, S., Parker, L., & Kripke. D. F. (1989). Twenty-four-hour sleep-wake patterns
in a nursing home population. Psychology and Aging, 4, 352-356.
Joseph, J. A., & Roth, G. S. (1988). Up regulation of striatal dopamine receptors and improvement
of motor performance in senescence. In J. A. Joseph (Ed.), Central determinants of age-re-
lated declines in motor function. Annals of the New York Academy of Science, 15,
355-362.
Joseph, J. A., & Roth, G. S. (1993). Hormonal regulation of motor behavior in senescence. Journals
of Gerontology, 48 (Special Issue), 51-55.
Kagan, J., & Snidman, N. (1991). Temperamental factors in human development. American Psy-
chologist, 46, 856-862.
Kazenwadel, J., Pollmacher, T., Trenkwalder, C., Oertel, W. H., Kohnen, R, Kunzel, M., & Kruger,
H.-P. (1995). New actigraphic assessment method for periodic leg movements (PLM). Sleep,
18,689-697.
Kelley, J. E., & Lichstein, K. 1. (1980). A sleep assessment device. Behavioral Assessment, 2,
135-146.
King, A. C., Taylor, C. B., Haskell, W. 1., & DeBusk, R F. (1989). Influence ofregular aerobic exercise
on psychological health: A randomized, controlled trial of healthy middle-aged adults. Health
Psychology, 8, 305-324.
King, D. S., Dalsky, G. P., Clutter, W. E., Young, D. A., Staten, M. A., Cryer, P. E., & Holloszy, J. O.
(1988). Effects of exercise and lack of exercise on insulin secretion. American Journal of Phys-
iology, 254, E537-E542.
Kirwan, J. P., Kohrt, W. M., Wojta, D. M., Bourey, R E., & Holloszy, J. O. (1993). Endurance exercise
training reduces glucose-stimulated insulin levels in 60- to 70-year-old men and women. Jour-
nal of Gerontology: Medical Sciences, 48, M84-M90.
Kleitman, N. (1963). Sleep and wakefulness. Chicago: University of Chicago Press.
Knapp, D. N. (1988). Behavioral management techniques and exercise promotion. In R K. Dishman
(Ed.), Exercise adherence: Its impact on public health (pp. 203-235). Champaign, IL: Human
Kinetics.
Kraus, H., & Raab, W. (1961). Hypokinetic disease. Springfield, IL: Thomas.
Kripke, D. F., Ancoli-Israel, S., Klauber, M. R, & Wingard, D. 1. (1995). U.S. population estimate
for disordered sleep breathing: High rates in minorities. Sleep Research. 24, 268.
Kryger, M. H., Roth, T., & Carskadon, M. (1994). circadian rhythms in humans: An overview. In
M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (2nd
ed., pp. 301-308). Philadelphia: Saunders.
Kuo, T. F., Bootzin, R R, Bell, I. R, Wyatt, J. K" Rider, S. P., & Anthony, J. 1. (1995). Normative sleep
characteristics in the elderly: A six-night PSG study. Sleep Research 24, 125.
Lavie, P., Aharon-Peretz, J., Klein, F., Gruner, F., Epstein, R, Tzischinsky, 0., & Herer, P. (1992).
Sleep quality in geriatric depressed patients: Comparison with elderly demented patients and
normal controls and the effects of Moclobemide. Dementia, 3, 360-366.
Lavie, P., Epstein, R, Tzischinsky, 0., Gilad, D., Nahir, M., Lorber, M., & Scharf, Y. (1992). Acti-
graphic measurements of sleep in rheumatoid arthritis: Comparison of patients with low back
pain and healthy controls. Journal of Rheumatology, 19, 362-365.
LeBlanc, J., Nadeau, A., Richard, D., & Tremblay, A. (1981). Studies on the sparing effect of exer-
cise on insulin requirements in human subjects. Metabolism, 30, 1119-1124.
Leon, A. S., Connett, J., Jacobs, D. R, Jr., & Rauramaa, R (1987). Leisure-time physical activity lev-
els and risk of coronary heart disease and death. Journal of the American Medical Association,
258, 2388-2395.
Lieberman, H. R, Wurtman, J. J., & Teicher, M. H. (1989). Circadian rhythms of activity in healthy
young and elderly humans. Neurobiology of Aging, 10, 259-265.
Magnus, K, Matroos, A., & Strackee, J. (1979). Walking, cycling, or gardening, with or without sea-
sonal interruption, in relation to acute coronary events. American Journal of Epidemiology.
110,724-733.
Manton, K G., Stallard, E., & Liu, K. (1993). Forecasts of active life expectancy: Policy and fiscal im-
plications. Journals of Gerontology. 48 (Special Issue), 11-26.
Marston, A. R, & Criss, J. (1984). Maintenance of successful weight loss: Incidence and prediction.
International Journal of Obesity. 8, 435-439.
Martinsen, E. W. (1984). Interaction of exercise and medication in the psychiatric patient. Coping
with mental stress: The potential and limits of exercise intervention. Washington, DC: NIMH
Workshop.
Massie, c., Daniels, R, & Juszynski, G. (1995). Leg actigraphy: Preliminary normative data. Sleep
Research, 24, 284.
McAuley, E. (1992). The role of efficacy cognitions in the prediction of exercise behavior in middle-
aged adults. Journal of Behavioral Medicine, 15, 65-88.
McAuley, E. (1993). Self-efficacy and the maintenance of exercise participation in older adults.
Journal of Behavioral Medicine, 16,103-113.
McAuley, E., Courneya, K S., & Lettunich, J. (1991). Effects of acute and long-term exercise on
self-efficacy responses in sedentary, middle-aged males and females. Gerontologist, 31,
534-542.
McAuley, E., Lox, c., & Duncan, T. E. (1993). Long-term maintenance of exercise, self-efficacy, and
physiological change in older adults. Journal of Gerontology: Psychological Sciences, 48,
P218-P224.
McCann, I. L., & Holmes, D. S. (1984). Influence of aerobic exercise on depression. Journal of Per-
sonality and Social Psychology, 46, 1142-1147.
Middlekoop, H. A. M., & Kerkhof, G. A. (1990). Nocturnal wrist motor activity and subjective sleep
quality in young and elderly subjects. Journal of Interdisciplinary Cycle Research, 21,
218-219.
Minor, M. A., Hewett, J. E., Webel, R R, Anderson, S. K., & Ray, D. R (1989). Efficacy of physical
conditioning exercise in patients with rheumatoid arthritis and osteoarthritis. Arthritis and
Rheumatism, 32, 1396-1405.
Mintz, A. Y., & Mankovsky, N. B. (1971). Changes in the nervous system during cerebral athero-
sclerosis and aging. Geriatrics, 26, 134-144.
Mistleberger, R E., & Rusak, B. (1994). Circadian rhythms in mammals: Formal properties and en-
vironmental influences. In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and prac-
tice of sleep medicine (2nd ed., pp. 277-285). Philadelphia: Saunders.
Monk, T. H. (1994). Circadian rhythms in subjective activation, mood, and performance efficiency.
In M. H. Kryger, T. Roth, & W. C. Dement (Eds.), Principles and practice of sleep medicine (2nd
ed., pp. 321-330). Philadelphia: Saunders.
Moran, M. G., Thompson, T. L., & Nies, A. S. (1988). Sleep disorders in the elderly. American Jour-
nal of Psychiatry. 145,1369-1378.
Morris, J. N., Chave, S. P. W., Adam, C., Sirey, C., Epstein, L., & Sheehan, D. J. (1973). Vigorous ex-
ercise in leisure-time and the incidence of coronary heart-disease. Lancet, 1, 333-339.
Morris, J. N., Everitt, M. G., Pollard, R, Chave, S. P. w., & Semmence, A. M. (1980). Vigorous exer-
cise in leisure-time: Protection against coronary heart disease. Lancet, 2, 1207-1210.
Oberman, A. (1985). Exercise and the primary prevention of cardiovascular disease. American Jour-
nal of Cardiology. 55,100-200.
O'Brien, S. J., & Vertinsky, P. A. (1991). Unfit survivors: Exercise as a resource for aging women.
Ogilvie, RD., & Harsh, J. R (1994). Sleep onset: Normal and abnormal processes. Washington, DC:
American Psychological Association.
Ogilvie, RD., & Wilkinson, R T. (1988). Behavioral versus EEG-based monitoring of all-night sleep-
wake patterns. Sleep, 11,139-155.
Ogilvie, R D., Wilkinson, R T., & Allison, S. (1989). The detection of sleep onset: Behavioral, phys-
iological, and subjective convergence. Sleep, 12,458-474.
Paffenbenbarger, R S., Jr. & Hale, W. E. (1975). Work activity and coronary heart mortality. New En-
gland Journal of Medicine, 292, 545-550.
554 Warren W. Tryon
Paffenbarger, R. S., Jr., & Hyde, R. T. (1984). Exercise in the prevention of coronary heart disease.
Preventive Medicine, 13,3-22.
Paffenbarger, R. S., Jr., Wing, A. L., & Hyde, R. T. (1978). Physical activity as an index of heart attack
risk in college alumni. American Journal of Epidemiology. 108, 161-175.
Paffenbarger, R. S., Jr., Hyde, R. T., Wing, A. 1., & Steinmetz. C. H. (1984). A natural history of ath-
leticism and cardiovascular health. Journal of the American Medical Association, 252,
491-495.
Paffenbarger, R. S., Jr., Hyde, R. T., Wing, A. 1., & Hsieh, C. C. (1986). Physical activity, all-cause
mortality. and longevity of college alumni. New England Journal of Medicine, 314, 605-613.
Palmore, E. (1970). Health practices and illness among the aged. Gerontologist, 10,313-316.
Perry, T. J., & Goldwater, B. C. (1987). A passive behavioral measure of sleep onset in high-alpha and
low-alpha subjects. Psychophysiology, 24, 657-665.
Petruzzello, S. J., Landers, D. M., Hatfield, B. D., Kubitz, K. A., & Salazar, W. (1991). A meta-analy-
sis on the anxiety-reducing effects of acute and chronic exercise. Sports Medicine, 11,
143-182.
Pollak, C. P., Perlick, D., & Linsner, J. P. (1986). Sleep in the elderly: Survey of an urban community.
Sleep Research, 15,54.
Pollak, C. P., Perlick, D.. Linsner, J. P., Wenston, J., & Hsieh, F. (1990). Sleep problems in the com-
munity elderly as predictors of death and nursing home placement. Journal of Community
Health, 15, 123-135.
Pollak, C. P., Perlick, D., & Linsner, J. P. (1992). Daily sleep reports and circadian rest-activity cycles
of elderly community residents with insomnia. Biological Psychiatry, 32, 1019-1027.
Pollak, C. P., Ford, T., McGuire, P. J., Vaisman, S., & Zendell. S. (1995). Motor activity of community
elders and their caregivers. Sleep Research, 24, 536.
Powell, K. E., Thompson, P. D., Caspersen, C. J., & Kendrick, J. S. (1987). Physical activity and the
incidence of coronary heart disease. Annual Review of Public Health, 8, 253-287.
Powell, R. R. (1974). Psychological effects of exercise therapy upon institutionalized geriatric men-
tal patients. Journals of Gerontology. 29, 157-161.
Raoux, N., Benoit, 0., Dantchev, N., Denise, P., Franc, B., Allilaire, J. F., & Widlocher, D. (1994). Cir-
cadian pattern of motor activity in major depressed patients undergoing antidepressant ther-
apy: Relationship between actigraphic measures and clinical course. Psychiatry Research, 52,
85-98.
Rechtschaffen, A. (1994). Sleep onset: Conceptual issues. In R. D. Ogilvie & J. R. Harsh (Eds.), Sleep
onset: Normal and abnormal processes (pp. 3-17). Washington, DC: American Psychological
Association.
Redwood, D. R., Rosing, D. R., & Epstein, S. E. (1972). Circulatory and symptomatic effects ofphys-
ical training in patients with coronary artery diseases and angina pectoris. New England Jour-
nal of Medicine, 286, 959-965.
Reisberg, B., Borenstein, J., Salob, S. P., Ferris, S. H., Frannsen, E.. & Georgotas, A. (1987). Behav-
ioral symptoms in Alzheimer's disease: Phenomenology and treatment. Journal of Clinical
Renfrew, J. W., Pettigrew, K. D., & Rapoport, S. I. (1987). Motor activity and sleep duration as a func-
tion of age in healthy men. Physiology and Behavior, 41, 627-634.
Rogers, M. A., King, D. S., Hagberg, J. M., Ehsani, A. A., & Holloszy, J. O. (1990). Effect of 10 days of
inactivity on glucose tolerance in master athletes. Journal of Applied Physiology, 68,
1833-1837.
Rosnow, I., & Breslau, N. (1966). A Guttman health scale for the aged. Journals of Gerontology, 21,
556-559.
Sack, R. 1., Blood, M. L., Percy, D. 1., & Pen, J. C. (1995). A comparison of sleep onset latency mea-
sured by PSG, actigraphy and behavioral response. Sleep Research, 24, 540.
Sadeh, A. (1994). Assessment ofintervention for infant night waking: Parental reports and activity-
based home monitoring. Journal of Consulting and Clinical Psychology, 62, 63-68.
Sadeh, A., Sharkey, K., & Carskadon, M. A. (1994). Activity-based sleep-wake identification: An em-
pirical test of methodological issues. Sleep, 17,201-207.
Sadeh, A., Hauri, P. J., Kripke, D. F., & Lavie, P. (1995). The role of actigraphy in the evaluation of
sleep disorders. Sleep, 18, 288-302.
Salonen, J. T., Puska, P., & Tuomilehto, J. (1982). Physical activity and risk of myocardial infarction,
cerebral stroke and death: A Longitudinal study in eastern Finland. American Journal of Epi-
demiology. 115,526-537.
Sanford, J. R. A. (1975). Tolerance of debility in elderly dependents by supporters at home: Its sig-
nificance for hospital practice. British Medical Journal, 23, 471-473.
Satlin, A., Teicher, M. H., Lieberman, H. R., Baldessarini, R. J., Volicer, L., & Rheaume, Y. (1991).
Circadian locomotor activity in Alzheimer's disease. Neuropsychopharmacology. 5, 115-126.
Satlin, A., Volicer, L., Ross, V., Herz, 1., & Campbell, S. (1992). Bright light treatment of behavioral
and sleep disturbances in patients with Alzheimer's disease. American Journal of Psychiatry,
149,1028-1032.
Seals, D. R., Hagberg, J. M., Allen, W. K., Hurley, B. F., Dalsky, G. P., Ehsani, A. A., & Holloszy, J. O.
(1984). Glucose tolerance in young and older athletes and sedentary men. Journal of Applied
Physiology. 56, 1521-1525.
Sidney, K. H., & Shephard, R. J. (1977). Activity patterns of elderly men and women. Journals of
Gerontology. 32, 25-32.
Simons, A. D., McGowan, C. R., Epstein, 1. H., Kupfer, D. J., & Robertson, R. J. (1985). Exercise as a
treatment for depression: An update. Clinical Psychology Review, 5, 553-568.
Siu, A. 1., Hays, R. D., Ouslander, J. G., Osterwell, D., Valdez, R. B., Krynski, M., & Gross, A. (1993).
Measuring functioning and health in the very old. Journal of Gerontology: Medical Sciences,
48, M10-M14.
Slattery, M. L., Schumacher, M. C., Smith, K. R., West, D. W., & Abd-Elghany, N. (1988). Physical ac-
tivity, diet, and risk of colon cancer in Utah. American Journal of Epidemiology, 128, 989-999.
Slattery, M. L., Jacobs, D. R., Jr., & Nichaman, M. Z. (1989). Leisure time physical activity and coro-
nary heart disease death: The US railroad study. Circulation, 79, 304-311.
Snyder, F., & Scott, J. (1972). The psychology of sleep. In N. S. Greenfield & R. A. Sternback (Eds.),
Handbook of psychophysiology (pp. 645-708). Toronto, Ontario. Canada: Holt, Rinehart and
Winston.
Standards of Practice Committee. (1995). Practice parameters for the use of actigraphy in the clini-
cal assessment of sleep disorders. Sleep, 18, 285-287.
Stephens, T., Craig, C. L., & Ferris, B. F. (1986). Adult physical fitness in Canada: Findings from the
Canada Fitness Survey 1. Canadian Journal of Public Health, 77, 285-290.
Stickgold, R., & Hobson, J. A. (1994). Home monitoring of sleep onset and sleep-onset mentation us-
ing the Nightcap (trn). In R. D. Ogilvie & J. R. Harsh (Eds.), Sleep onset: normal and abnormal
processes (pp. 141-160). Washington, DC: American Psychological Association.
Stones, M. J., & Kozma. A. (1989). Age, exercise, and coding performance. Psychology and Aging, 4,
190-194.
Svanborg, E., Larsson. H., Carlsson-Nordlander, B., & Pirskanen, R. (1990). A limited diagnostic in-
vestigation for obstructive sleep apnea syndrome. Chest, 98, 1341-1345.
Teicher, M. H., Lawrence, J. M., Barber, N. I., Finklestein, S. P., Lieberman, H. R., & Baldessarini,
R. J. (1988). Increased activity and phase delay in circadian motility rhythms in geriatric de-
pression. Archives of General Psychiatry, 45, 913-917.
Teri, 1., Larsen, E. B., & Reifler, B. V. (1988). Behavioral disturbance in dementia of Alzheimer's
type. Journal of the American Geriatric Society, 36, 1-6.
Thoman, E. B., Acebo, C., & Lamm, S. (1993). Stability and instability of sleep in older persons
recorded in the home. Sleep, 16, 578-585.
Trenkwalder, C., Stiasny, K., Pollmiicher, T., Wetter, Th., Schwarz, J., Kohnen, R., Kazenwadel, J.,
KrUger, H. P., Ramm, S., Kunzel, M., & Oertel, W. H. (1995). L-dopa therapy of uremic and
ideopathic restless legs syndrome: A double-blind, crossover trial. Sleep, 18,681-688.
Tryon, W. W. (1985). The measurement of human activity. In W. W. Tryon (Ed.), Behavioral assess-
ment in behavioral medicine (pp. 200-256). New York: Springer.
Tryon, W. W. (1993). The role of motor excess and instrumented activity measurement in Attention-
Deficit Hyperactivity Disorder. Behavior Modification, 17, 371-406.
Tryon, W. W. (1996). Nocturnal activity and sleep assessment. Clinical Psychology Review, 16,
197-213.
Tryon, W. W. (1997). Motor Activity and DSM-IV. In. S. M. Turner & M. Hersen (Eds.), Adult psy-
chopathology and diagnosis (3rd ed., pp.547-577). New York: Wiley.
556 Warren W. Tryon
Tryon, W. W., & Williams, R (1996). Fully proportional actigraphy: A new instrument. Behavior Re-
search Methods Instruments &" Computers, 28, 392-403.
Tune, G. S., (1968). Sleep and wakefulness in normal human adults. British Medical Journal, 2,
269-271.
Van Gool, W. A., & Mirmiran, M. (1986). Aging and circadian rhythms. Progress in Brain Research,
70,255-277.
van Hilten, B., Hoff, J. 1., Huub, A. M., Middelkoop, M. A., van der Velde, E. A., Kerkhof, G. A.,
Wauquier, A., Kamphuisen, H. A. C., & Roos, R A. C. (1994). Sleep disruption in Parkinson's
disease. Archives of Neurology, 51, 922-928.
van Hilten, J. J., Braat, E. A. M.. van der Velde, E. A., Middelkoop. H. A. M., Kerhof, G. A., & Kam-
phuisen, H. A. C. (1993). Ambulatory activity monitoring during sleep: An evaluation of in-
ternight and intrasubject variability in healthy persons aged 50-98 years. Sleep, 16, 146-150.
van Hilten, J. J., Middelkoop, H. A. M., Kuiper, S. 1. R, Kramer, C. G. S., & Roos, R A. C. (1993).
Where to record motor activity: An evaluation of commonly used sites of placement for activ-
ity monitors. Electroencephalography and Clinical Neurophysiology, 89, 359-362.
van Someren, E. J. w., Mirmiran, M., & Swaab, D. F. (1993). Non-pharmacological treatment of sleep
and wake disturbances in aging and Alzheimer's disease: Chronobiological perspectives. be-
havioral Brain Research, 57, 235-253.
Viens, M., De Koninck, J., Van den Bergen, R, Audet, R, & Christ, G. (1988). A refined switch-acti-
vated time monitor for the measurement of sleep-onset latency. Behaviour Research and Ther-
apy. 26, 271-273.
Wallace, J. E., Krauter, E., & Campbell, E. (1980). Motor and reflexive behavior in the aging rat. Jour-
nals of Gerontology, 35, 364-370.
Webb, W. B. (1968). Sleep: An experimental approach. New York: Macmillan.
Webster, J. B., Messin, S., Mullaney, D. J., & Kripke, D. F. (1982). Transducer design and placement
for activity recording. Medical &" Biological Engineering &" Computing, 20, 741-744.
Weinert, D., Sitka, U., Minors, D. S., & Waterhouse, J. M. (1994). The development of circadian
rhythmicity in neonates. Early Human Development, 36, 117-126.
Westover, S. A., & Lanyon, R 1. (1990). The maintenance of weight loss after behavioral treatment.
Behavior Modification, 14, 123-137.
Wever, R A. (1979). The circadian system of man: Results of experiments under temporal isolation.
New York: Springer-Verlag.
Winograd, C. H., & Jarvik, L. F. (1986). Physician management of the demented patient. Journal of
the American Geriatric Society, 34, 295-308.
Witting, W., Kwa, 1. H., Eikelenboom, P., Mirmiran, M., & Swaab, D. F. (1990). Alterations in the cir-
cadian rest-activity rhythm in aging and Alzheimer's disease. Biological Psychiatry, 27,
563-572.
Woollacott, M. H. (1993). Age-related changes in posture and movement. Journals of Gerontology,
48 (Special Issue), 56-60.
Zuckerman, M. (1991). Psychobiology of personality. Cambridge, England: Cambridge University
Press.
CHAPTER 25
Approaches to Diagnosis and

Treatment of Elder Abuse
and Neglect
RONALD D. ADELMAN, HENNA SIDDIQUI,
AND NANCY FOLDI
INTRODUCTION
A 1991 congressional report estimated that each year 1.5 to 2 million older peo-
ple are physically injured, psychologically mistreated, financially exploited, or
neglected by family members (U.S. Congress, House Select Committee on Ag-
ing, 1991). Because much of this abuse and neglect occurs between spouses,
this phenomenon must be viewed in the context of domestic violence, and
much of it constitutes criminal offenses.
Elder abuse and neglect has been called a silent epidemic. Often, the elderly
victim is reluctant to divulge mistreatment due to overwhelming feelings of
shame and fear. It is highly probable that many older victims are never discov-
ered. Indeed, some estimate that only 1 in 14 elder abuse or neglect cases is ac-
tually reported to a public agency (American Medical Association Diagnostic
and Treatment Guidelines on Elder Abuse and Neglect, 1992). Given the present
incidence of mistreatment and the projected growth of the older population, it is
crucial that health care providers for the elderly learn to recognize and intervene
on behalf of victimized older people. However, it must be recognized that the in-
formation base about abuse and neglect of older persons is limited. More re-
search is needed to better understand the causes of elder mistreatment, tactics to
RONALD D. ADELMAN • Division of Geriatrics and Gerontology, New York Hospital-Cornell Medical
Center, New York, New York 10021. HENNA SIDDIQUI • Division of Geriatrics, Winthrop-Uni-
versity Hospital, Mineola, New York 11501, NANCY FOLDI • Division of Neurology,
Winthrop-University Hospital, Mineola, New York 11501.
557
558 Ronald D. Adelman et al.
prevent this problem, and ways to successfully intervene. The goals of this chap-
ter are to define family-mediated elder abuse and neglect, to discuss approaches
to detection and assessment, and to outline possible strategies for intervention.
EPIDEMIOLOGY
The epidemiology of elder mistreatment has been better understood since

the results of a 1986 survey conducted by the Family Research Laboratory at the
University of New Hampshire (Pillemer & Finkelhor, 1988). Two thousand
twenty randomly selected elderly people living in the Boston metropolitan area
were interviewed and 32 of every 1,000 people 65 years of age and older re-
ported being mistreated. Abuse was defined as physical abuse, which included
hitting, slapping, and pushing; neglect involved depriving a person of something
needed for daily living; and chronic verbal aggression included verbal threats
and insults. Because this survey did not include financial exploitation and other
forms of elder mistreatment, the 3.2% incidence underestimates the problem
The Family Research Laboratory investigators discovered that most abuse
is committed by one spouse against another; 65 % of abuse cases were between
spouses, whereas only 23% involved an adult child abusing a parent. Of note
was that elderly husbands were abused twice as often as elderly wives. It is not
known whether the abuse perpetrated by wives was a form of retaliation. Also,
the survey found that elderly wives are more seriously injured by their hus-
bands than elderly husbands are by their wives.
Recently, the Women's Initiative of the American Association of Retired
Persons categorized family-mediated elder abuse and neglect as follows: (l)
early-onset spousal and partner abuse and neglect continuing into later life, (2)
late-onset spousal and partner abuse and neglect during later life, and (3) abuse
and neglect by adult children and other relatives (Adelman & Breckman, 1995).
Another important finding from the University of New Hampshire study
was that the abusers usually were dependent on the person they abused, for ex-
ample, an adult child dependent for housing and economic support. Close
proximity of living arrangements of victim and abuser was noted to be a signif-
icant risk factor for the occurrence of abuse and neglect; elderly individuals liv-
ing alone were less likely to experience abuse. The survey also demonstrated
that mistreatment occurred across all economic levels, religions, and age groups
among the elderly.
DEFINITIONS
There are three main forms of elder mistreatment: physical, psychological,

and financial. Physical abuse and neglect includes striking, shoving, beating,
restraining, or feeding improperly. Sexual assault is also included under this
subheading. Psychological abuse and neglect may manifest in threatening re-
marks, insults, commands, or ignoring the older individual. This form of abuse
and neglect causes emotional stress for an older person. Ageist behavior in the
Elder Abuse and Neglect 559
form of infantilism, whereby the older person is treated as a child, also consti-
tutes a form of psychological mistreatment. Financial abuse and neglect in-
cludes the misuse or exploitation of or inattention to an older person's
possessions or funds. Conning, pressuring an older individual to distribute as-
sets, or irresponsibly managing the victim's money comprise financial mis-
treatment. It is important to realize that usually several types of abuse co-occur.
For example, if an elderly woman is being physically abused by her alcoholic
son, she is likely to be experiencing psychological mistreatment as well (Breck-
man & Adelman, 1988).
THEORIES OF CAUSATION
There are four main theories of causation for elder abuse and neglect. More
research needs to be done to properly substantiate these suggested etiologies.
The theories include (1) psychopathology ofthe abuser; (2) stress; (3) transgen-
erational violence; and (4) dependency (Pillemer, 1986)
Psychopathology of the Abuser
The disproportionate numbers of abusers with serious psychiatric condi-

tions and drug and alcohol problems is the basis for this etiologic theory (Wolf
& Pillemer, 1989). Health professionals working in psychiatric institutions
should become aware of elder abuse and neglect. When an adult child has a psy-
chiatric illness requiring hospitalization, the patient may often be discharged to
the parents' home. Patients who are not violent while institutionalized can be vi-
olent at home. Careful scrutiny for the potential for domestic violence must be
part of every discharge plan. Therefore, appropriate provisions for follow-up are
essential if prevention of elder mistreatment is a priority.
Stress
Death in the family, financial stresses, the responsibilities of caregiving,

and other tensions can create anger and frustration that some individuals ex-
press through acts of violence (Strauss, Gelles, & Steinmetz. 1980). One study
investigated family violence with Alzheimer's disease patients and found that
5.4% of caregivers in the study were violent to the patients. The variables most
associated with violence were caregiver depression and living arrangements
(Paveza, Cohen, Isdorfer, & Freels, 1992).
Transgenerational Violence
This etiologic concept theorizes that violent behavior is a learned method

of expressing anger and frustration (Wolf & Pillemer, 1989). This theory postu-
lates that when children are treated with violence, they develop the same pat-
terns of behavior from direct observation.
Dependency
This theory postulates that when family members are dependent on an

older relative for housing, finances, emotional support, and other needs, the de-
pendent family member may become resentful and then be predisposed to abu-
sive or neglectful behavior (Hwalek, Sengstock, & Lawrence, 1984; Pillemer &
Finkelhor, 1988; Wolf, Godkin, & Pillemer, 1984). This theory also implies that
older individuals who are cognitively or functionally dependent on their fami-
lies for care are at increased risk for abuse and neglect.
These four unproven etiologic theories should be conceptualized as poten-
tial risk factors for elder abuse and neglect. Systematically inquiring about the
issues incorporated in these theories is useful to the health professional seeking
to detect and evaluate this form of domestic violence.
DETECTION
There are many factors that make detection of elder abuse and neglect dif-
ficult. These factors can be divided into two basic types: the barriers of detec-
tion caused by issues of the health care professional and the barriers that are
secondary to issues of the victim or the abuser. These barriers are discussed in
the following sections.
Aiding in Detection: Training of Health Care Professionals
It is incumbent on the community of health care professionals to be able to

detect abuse in the elderly. To facilitate this, every clinical setting should have
a protocol for detecting elder mistreatment. At the Mount Sinai/Victim Services
Agency Elder Abuse Project, geriatricians-in-training were trained in such de-
tection (Ansell & Breckman, 1988).
Interview Rules
When interviewing an older patient, particularly an individual accompa-
nied by a relative, it is crucial to spend some time with the older person alone.
This provides opportunity not only to detect mistreatment, but also to provide
a forum in which to establish rapport with the identified individual. The inter-
view (and when appropriate the physical examination) should be performed
completely separately from an accompanying relative who is suspected of mis-
treatment (Quinn & Tomita, 1986). Barriers to detection are numerous, but
when a victim does not even have the opportunity for confidential interaction,
affinity with the health provider will be difficult to develop. Without a trusting
relationship between health professional and older victim, mistreatment most

likely will go undetected.
Questions to Ask
As health care professionals are rarely trained in detection, it is helpful to
have available concrete questions that can be used. In the program at the Mount
Sinai Medical SchoollVictim Services Agency Elderly Abuse Project from New
York City, geriatriciains-in-training were instructed to direct some of these
questions to patients:
• Has anyone at home ever hurt you?
• Has anyone ever touched you without your consent?
• Has anyone ever made you do things you didn't wish to do?
• Has anyone taken anything that was yours without asking?
• Has anyone ever scolded or threatened you?
• Have you ever signed any documents that you didn't understand?
• Are you afraid of anyone at home?
• Has anyone ever failed to help you take care of yourself when you
needed help?
These questions can be utilized by psychologists, nurses, social workers, and
physicians (Ansell & Breckman, 1988).
Detection of Physical Abuse

Physical abuse and neglect can be manifested by unexplained injuries or
evidence inconsistent with medical findings. For example, if an x-ray reveals
multiple fractures of different ages and this evidence does not fit the clinical
past and present history provided, the clinician should be suspicious of un-
derlying mistreatment. Signs may include fractures, welts, lacerations, bums,
and bruises. Suspicion of sexual abuse must be considered when any of the
following is noted: tom or bloody underclothing; difficulty in walking or sit-
ting; discomfort, itching or bruising in the genital area; or unexplained vene-
real disease or genital infections. Additional signs or symptoms of physical
mistreatment include dehydration, malnutrition, hypothermia or hyperther-
mia, poor hygiene in a dependent older patient, inadequate or inappropriate
clothing, and lack of supportive devices such as eyeglasses, hearing aids, or
dentures. Unexpected or unexplained deterioration in an older person's health
should also be evaluated. The presence of decubitus ulcers or signs of mismed-
ication also require investigation.
Health care personnel must investigate the specifics of each injury and not
misattribute conditions because of incomplete history taking or ageist stereo-
typing. For example, the health professional should assess each new fracture. A
relative accompanying an older patient with a fracture may attribute the prob-
lem to a fall caused by poor balance. Although falls are common in the aging
population, the injury needs to be carefully assessed and the possibility of
abuse must be considered.
Observations
Certain types of behavioral observations by the health professional are
helpful in the detection of elder mistreatment. The professional should con-
sider possible elder abuse and neglect when any of the following instances are
observed (Breckman & Adelman, 1988):
• the patient appears fearful of a family member;
• the patient appears reluctant to respond when questioned;
• the patient and family member have conflicting stories as to how an
event occurred;
• the health professional observes the family member to be hostile, angry,
or impatient with the elderly individual;
• the family member is overly concerned about costs for necessary items
for the older individual (e.g., radiology tests, hearing aid);
• the family member tries to prevent the health professional from interact-
ing with the older individual privately;
• the family member prevents or resists necessary services from coming
into the home (e.g., visiting nurse, physical therapy).
Aiding in Detection: Barriers of Victims and Abusers
Although personnel in mental health and medical settings need training,

it is equally important to highlight situations in which the abuser and victim
present with specific features that should raise suspicion.
Factors in the Victim

Several aspects of the victim make it difficult to detect abuse or neglect.
Clearly, the victim may feel shame and not be able to disclose mistreatment.
Fear of retaliation may be another impediment. Another formidable barrier to
detection is the lack of awareness about this phenomenon on the part of older
people: victims may be unable to report abuse or neglect because they are not
aware that what they are experiencing qualifies as mistreatment.
Factors in the Abuser

The abuser also plays a role in creating barriers to detection. Certain risk
factors, however, should raise suspicion.
Deterring Contact. Naturally, the abuser may deter the possibility of hav-
ing the victim come into contact with health care professionals or friends. The
older individual may be newly isolated in that he or she does not have oppor-
tunities to be with other people or pursue desired activities. This may also take
the form of preventing the victim from seeing health professionals (e.g .. missed
or delayed appointments). The abuser also may prevent anyone health profes-
sional from seeing the whole picture (consider the pattern of physician or hos-
pital "hopping"). For example, an abuser who is responsible for multiple
fractures can probably avoid seeing the same physician or emergency room to
conceal a pattern of behavior that would indicate mistreatment.
The perpetrator also holds a certain authority over and can instill fear in
the victim, affecting the presentation to the outside world. This may take the
form of the victim's not revealing information for fear of retaliation from the
abuser, thus not disclosing events.
Other Risk Factors of the Abuser. Certain psychological or physical or

environmental risk factors of the abuser should raise suspicion. For example,
there may be a family member with a history of mental illness or a drug or al-
cohol problem; or there may be a history of violence in the family; the patient
or family member may be dependent on the other for housing, finances, or emo-
tional support; or there may be stress in the family (e.g., loss of job, death of a
significant other).
ASSESSMENT
Once there is suspicion of elder abuse or neglect, a careful assessment of

the victim's situation must be made. This evaluation needs to be extensive and
to include both medical and psychosocial parameters.
Victim Access
The first component to assess is the access the provider will have to the
victim. The abuser usually limits the victim's exposure to the outside world and
often refuses to allow a professional to visit the home. Abusers closely monitor
the victim's contact with the outside world to prevent disclosure of mistreat-
ment. Often, the health professional is the only individual to whom the victim
has access which underscores the importance of health providers' recognizing
this form of domestic violence. In general, the key to access is persistence and
tenacity on the part of the health professional. At times, health professionals
need to become quite ingenious to gain access to the isolated victim.
Abuse Pattern
Mistreatment often increases in severity and frequency over time. If the

pattern of abuse has escalated, and the older victim is being severely abused,
the victim may be in serious danger.
Assessment of Emergency
The health provider must decide whether emergency intervention needs to

be taken. Professionals in the aging network may not be knowledgeable about
the seriousness of domestic violence and its criminal context. A victim's life
may be in jeopardy; therefore, careful scrutiny of the victim's safety is a critical

component of assessment. An outlook that emphasizes that mistreatment is de-
rived primarily from caregiver stress undermines a domestic violence perspec-
tive and the seriousness of elder abuse and neglect.
Intentionality
It is imperative to learn whether the abuse is intentional. For example, de-

termining that a relative intended to cause harm by mismedicating an older in-
dividual (versus nondeliberate mismedication occurring from an improper
understanding of the physician's orders) has significant implications for the ap-
proach toward intervention.
Who Is Abusing?
The assessment should also attempt to determine who is inflicting the

abuse. There may be more than one perpetrator and an accurate assessment is
crucial in order to determine appropriate interventions. For example, it must be
ascertained whether the suspected abuser is a family member.
Assessing the Interpersonal Dynamic Situation
Dependency profiles of both the victim and the abuser need to be deter-
mined. Is the victim dependent on the abuser or is the abuser the dependent
one? External stresses, such as unemployment, retirement, and the death of
someone close, are considered potential risk factors for elder mistreatment.
It is important to ascertain whether the victim perceives the seriousness of
the problem or denies the presence of abuse and neglect. The victim's aware-
ness of the mistreatment and whether the victim is in denial or recognizes the
problem will ultimately determine the types of intervention options available
to the victim at his or her present stage of awareness.
Cognitive, Psychological, and Physical Level of the Abused
The assessment must determine whether the victim is cognitively im-

paired. Typically, this will involve a neuropsychological evaluation of the vic-
tim that will be used to determine the level of comprehension or appreciation
of the situation. That is, does the victim appreciate the risks of staying in an
abusive situation? Is the victim competent to access help, follow a safety plan,
and escape if abuse recurs? Similarly, any active psychological symptoms sec-
ondary to Axis I or Axis II diagnoses (e.g., psychosis, depression, or significant
stressors) need to be assessed. Their contributions can significantly affect the
victim's ability to follow any future recommendations. The victim's medical
status is also important to determine: Is there a medical condition or mobility
problem that will require special management? For example, if the patient is
wheelchair-bound, this may limit the use of certain shelters that are not set up
for the nonambulatory.
Resources
The victim's resources need to be determined. What financial resources

does the patient have? Does the victim own his or her residence? What emo-
tional support is available to the victim? Are there concerned family and
friends who are willing to help the victim?
INTERVENTION
Intervention can be planned only after a thorough assessment has been

conducted. After assessment, the health professional will understand the sever-
ity of maltreatment, the victim's insight into the abuse, the victim's cognitive ca-
pabilities, the victim's resources, and community resources (Breckman &
Adelman, 1988). Intervention can then occur in several areas: safety, treatment
of the victim, treatment of cause of mistreatment, and criminal and legal steps.
These are discussed in the sections below.
Safety
Immediate action must take place if the assessment reveals that the victim
is in danger. Information about previous interventions is crucial. For example,
if previous court orders of protection were not successful, it is essential to de-
termine why, so that the same failed approach is avoided. Provision of emer-
gency supports is an integral part of intervention. If an older victim is
endangered, providing respite housing or help in getting immediate medical at-
tention may be the first line of action.
Treatment of the Victim
It is essential to determine the victim's awareness of the mistreatment.

Breckman's model (Breckman & Adelman, 1988) is a useful tool with which to
understand the victim's state of mind concerning elder mistreatment. Breckman
categorizes victims according to the following stages: denial, recognition, or re-
building. Although Breckman's model acknowledges that a victim's stage of
awareness can fluctuate, it is important that the worker plan interventions that
are appropriate for the victim's level of awareness; otherwise, the intervention
is likely to fail. For example, if an older victim is still in a stage ofreluctant ad-
mission about her adult son who is perpetrating violence, it is unlikely that she
will proceed with a court order of protection against him.
Another essential part of intervention is the provision of psychological treat-
ment. If physical or financial mistreatment is occurring the older individual
must also be experiencing psychological victimization. Individual counseling or

psychotherapy is necessary for the victim to begin to rebuild self-esteem and re-
cover from the effects of victimization. Victims of elder mistreatment have found
that participation in a victims' support group is beneficial. In addition, elder
abuse victims are often depressed. Among the elderly, depression can manifest
with cognitive changes that are reversible with appropriate treatment. Therefore,
a careful mental health assessment is paramount in a comprehensive interven-
tion strategy. Naturally, counseling the elder abuse victim should be viewed as a
long-term endeavor; the mental health professional should anticipate progress in
incremental steps, rather than in rapid advances with short-term resolution.
Some older victims are reluctant to report mistreatment because they fear
the only option available to them is admission to a nursing home. Interventions
that are successful in eliminating the source of violence will allow the older
victim to reclaim his or her home. When this is not possible, exploring alterna-
tive living arrangements is another intervention possibility. Adult homes, life-
care communities, and senior housing are possible options.
Providing educational information is a major focus of intervention. Educa-
tion includes teaching victims about abuse and neglect and teaching them that
options do exist. It also includes teaching victims to devise safety plans to fol-
low if they are endangered.
Nonemergent medical assistance is also crucial. Mistreatment victims often
have been neglected medically and after detection of mistreatment these needs
must be addressed.
Treatment of Causes
Assistance that addresses causes of elder abuse and neglect is a third line
of intervention. For example, referral to drug or alcohol rehabilitation can be of-
fered to addicted abusers and respite services or home care support can be
arranged for stressed caregivers. Psychotherapeutic work with the abuser (e.g.,
support groups for caregivers) may also be indicated as a vehicle to keep an al-
liance with those who may still be involved in the victim's care. It is important
to recognize that abusers usually do not abuse continuously, and between
episodes they may display fairly normal behavior. Unless there are persons who
can fill the void in the life of the victim if the abuser is removed, it may be ex-
tremely difficult for the older victim to forgo contact with the abuser.
Legal and Criminal Issues
Health professionals must become familiar with their state laws. If manda-
tory reporting is not required, the health professional can present options to the
mentally competent victim who can then decide how to proceed. When a vic-
tim is cognitively impaired, most decisions are better made by an interdiscipli-
nary team. Decisions need to be made with full awareness of the severity of the
violence, the lifestyle choice history of the individual, and the legal ramifica-
tions. Protective service laws govern intervention and reporting for incompe-
tent victims; thus again, health professionals need to be familiar with these state
laws. When a victim is ready to embark on a legal route, providing legal aid is
an essential part of intervention. If a victim is going to obtain an order of pro-
tection through family or criminal court, advocacy for the older victim through
the criminal justice system is indispensable.
REFERENCES
Adelman, R., & Breckman, R. (1995). Elder abuse and neglect. In The Merck manual of geriatrics
(2nd ed., pp. 1408-1416). Whitehouse Station, NJ: Merck.
American Medical Association diagnostic and treatment guidelines on elder abuse and neglect.
(1992). Chicago: American Medical Association.
Ansell, P., & Breckman, R. (1988). Assessment of elder mistreatment: Issues and considerations. El-
der mistreatment guidelines for health care profession: Detection, assessment and interven-
tion. New York: Mount SinaiIVictim Services Agency's Elder Abuse Project.
Breckman, R. S., & Adelman, R. D. (1988). Strategies for helping victims of elder mistreatment. New-
bury Park, CA: Sage.
Hwalek, M., Sengstock, M., & Lawrence R. (1984, November). Assessing the probability of abuse of
the elderly. Paper presented at the annual meeting of the Gerontological Society of America,
San Antonio, TX.
Paveza, G., Cohen, D., Eisdorfer, C., & Freels, S. (1992). Severe family violence and Alzheimer's dis-
ease: Prevalence and risk factors. Gerontologist, 32 (4), 493-497.
Pillemer, K. (1986). Risk factors in elder abuse: Results from a case-control study. In K. Pillemer &
R. Wolf (Eds.), Elder abuse: conflict in the family (pp. 236-266). Dover, MA: Auburn House.
Pillemer, K., & Finkelhor, D. (1988). The prevalence of elder abuse: A random sample survey. Geron-
tologist, 28, 51-57.
Quinn, M., & Tomita, S. (1986). Elder abuse and neglect. New York: Springer.
Strauss, M., Gelles. R.. & Steinmetz. S. (1980). Behind closed doors: Violence in the family. Garden
City. NY: Anchor/Doubleday.
U.S. Congress. House Select Committee on Aging. (1991). Elder abuse: What can be done? Wash-
ington, DC: U.S. Government Printing Office.
Wolf, R.. & Pillemer. K. (1989). Helping elderly victims: the reality of elder abuse. New York: Co-
lumbia University Press.
Wolf. R.. Godkin. M.. & Pillemer, K. A. (1984). Elder abuse and neglect: Report from the model pro-
jects. Worcester: University of Massachusetts Medical Center, University Center on Aging.
Index
Age Discrimination in Employment Act behavioral approaches, 55-67

(ADEA),385 behavior modification, 55-64
Ageism, 52-53 assessment, 55-56
Aging, 3-15 problem definition of, 56-57
biases associated with, 450 treatment evaluation, 60
demographics of, 3, 19 treatment implementation, 58-60
and heterogeneity of population, 26-27 treatment planning, 57-58
AIDS; see HIV cognitive-behavioral, 67
Alzheimer's Disease, 116, 277, 325, 338-339. Florida model, 60-62
340; see also Dementia self-management, 65-66
American Association on Mental Deficiency behavioral model, 51-52
(AAMD) Adaptive Behavior advantages of, 52-55
Scale, 326 problems associated with. 62-64
American Association on Mental Retardation consistency. 62
(AAMR), 323 dementia, 63-64
American Geriatrics Society, 8 generalization, 63
American Psychological Association (APA) Di- placement, 64
vision on Adult Development Behavioral medicine, 351-372
and Aging (Division 20), 19 definition of, 352-353
Anxiety, 217-238 Beliefs and Attitudes about Sleep Scale,
age of onset, 219-220 283
assessment, 224-229 Bereavement, 431-445
clinician ratings, 224-226 characteristics. 432
self-ratings. 226-229 effects, 435-440
comorbidity, 223-224 on mental health, 438-440
demographic correlates of, 220-221 on mortality and morbidity, 435-438
nature of, 221-222 grief and older adults, 433-434
prevalence of, 218-219 social support in the context of, 440-442
treatment, 229-233 stages, 432-433
cognitive-behavioral, 231-233 treatment, 442-445
pharmacological,230-231 Brief Symptom Inventory, 282
utilization of services, 229-231
Anxiety Disorders Interview Schedule (ADIS), Cardiovascular responsivity (CVR), 481
224,233 Caregiving, 469-486
Arousal Predisposition Scale, 283 caregiver distress, 477-480
ethnic and cultural minorities as family
Baltimore Longitudinal Study of Aging, 9 caregivers, 482
Beck Depression Inventory (BDI), 202, 233, historical aspects of, 470
282,473 informal caregiving, 470-471
Behavior Analysis Form (BAF), 61 men in caregiving role, 480-482
Behavioral gerontology, 51-68 psychological aspects of, 471-477
569
570 Index
Center for Epidemiological Studies-Depression Diagnostic and Statistical Manual of Mental

Scale (CES-D), 202, 473 Disorders. 4th Edition
Chronic obstructive pulmonary disease (DSM-IV), 114, 154, 177, 196.
(COPD),278 201.224,251,303.312
Cognitive restructuring (CR), 66 Down syndrome, 324, 325, 330. 338-339
Comprehensible Assessment and Referral Eval- Duke Adaptation Study, 9
uation (CARE), 202
Consensus Development Conference on Diag- Eating disorders. 357
nosis and Treatment of Depres- Elder abuse and neglect, 557-567
sion in Late Life. 203 assessment, 563-565
Coolidge Axis II Inventory (CAT!), 311, definitions, 558-559
313 detection, 560-563
Creutzfeldt-Jakob Disease, 121 epidemiology, 558
etiology, 559-560
Dementia, 63-64,113-141 intervention, 565-567
circadian rhythms, 544-545 prevalence, 557-558
decisional capacity and, 78 Epidemiological Catchment Area Study (ECA),
definition of, 113-115 195,217,229
diagnosis, 125-134 Ethical considerations, 71-85
ethical considerations, 76-79 ethical code, 72-74
general medical conditions and, 118 benefits, 72-73
treatment, 134-141 limitations, 73-74
types, 115-125 moral thinking, 75-76
Depression, 195-216 special concerns of geropsychology, 76-85
assessment, 200-203 Ethical Considerations and Code of Conduct,
circadian rhythms in, 545 71
depressive disorders, 195-197
age of onset, 197 Falls, behavioral medicine interventions for,
classification, 196-197 365-367
prevalence, 195
etiology, 197-200
Generalized Anxiety Disorder (GAD), 218, 221,
physical illness, 199-200
222-223,225,227,229,233
physiological factors, 199
Geriatric Depression Scale (GDS), 202
psychosocial factors, 198
Gerontological Society of America, 8
treatment, 203-211
Gerontology Alcohol Project (GAP), 160
biological, 206-211
Geropsychology, 3-15
electroconvulsive therapy (ECT),
clinical issues, 24-27
207-208
heterogeneity of population, 26-27
pharmacotherapy, 208-211
placement. 26
monoamine oxidase inhibitors
under-utilization. 24-25
(MAOIs), 210
funding, 25
selective serotonin reuptake in-
ethical issues, 76-85
hibitors (SSRIs), 210-211
assessment, 79-80
tricyclics, 209
decisional capacity, 76-79
psychotherapy, 203-206
suicide, 81-83
cognitive-behavioral, 204
existential considerations, 83-87
interpersonal, 204-205
future perspectives, 13-15
psychodynamic, 205
historical aspects, 3-13
reminiscence, 205-206
journals in, 12
Diagnostic Interview Schedule (DIS), 201
mental health, 4-5
Diagnostic and Statistical Manual of Mental
variables of study in, 4
Disorders, 301
Diagnostic and Statistical Manual of Mental
Disorders, 3rd Edition-Re- Hamilton Anxiety Rating Scale (HARS), 225,
vised 233
(DSM-III-R), 202, 223, 224, Hamilton Rating Scale for Depression (HRS-D),
225,227,281,303,313,414 202,226,233
Index 571
Head trauma, as cause of dementia, 118-119 treatment, 332-339

Health Maintenance Organizations (HMOs), 23 behavioral interventions, 332-333
HIV, 118, 362-364 in Down syndrome and Alzheimer's dis-
Hopkins Symptoms Checklist (HSCL), 219, 226 ease, 338-339
Huntington's disease, 120 phYSical/motor ability, 337-338
psychotropic medication, 332
International Personality Disorder Examina- Michigan Alcoholism Screening Test (MAST),
tion,312 155
Millon Clinical Multiaxial Personality Inven-
tory, (MCMI), 309, 310-311,
Kansas City Studies of Adult Life, 10 313
Minnesota Multiphasic Personality Inventory
Longitudinal Interval Follow-up Evaluation (MMPI), 309-310, 313
(LIFE),202 Minority issues, 505-518
caregiving, 514-515
Marital relations, 450-464 demographics, 506-509
and divorce, 455-456 in mental health, 511-514
and gender, 451-452 in physical health, 509-511
and long-term intimate relationships, Missouri Inpatient Behavioral Scale (MIBS),
452-453 226
impact of marital therapy on, 457-458 Mourning, 45-48
diagnostic issues, 462 Multidimensional Functional Assessment
procedures for older adults, 462-463 Questionnaire (MFAQl, 202
the 7Cs model, 459-461
impact ofremarriage on, 456-457 National Drug and Alcoholism Treatment Unit
impact of retirement on, 454-455 survey, 157
in older versus younger marriages, 451 National Institute of Mental Health (NIMH), 11,
problem areas, 453-454 25,217
McArthur Foundation Successful Aging stud- National Institute on Aging (NIA), 11
ies, 195 National Institutes of Health (NIH), 9
McGill Pain Questionnaire (MPQl, 416 National Nursing Home Survey (NNHS), 328
Medicare, 10, 21-22 Nocturnal penile tumescence (NPT), 263
Memory, 87-105
interventions, 98-101
Obesity, 356
applications of, 102-103
Older Alcohol Rehabilitation (OAR), 157
implications for clinical practice, 103-105
Older Americans Resources and Services
with cognitively impaired, 101-102
(OARS),202
normal memory aging, 88-89
Older Americans Act (OAA), 10
cognitive mechanisms, 96-97
definition of, 88
individual differences in, 94-95 Pain management, 411-424
long-term memory, 91-94 and anxiety, 414
non-cognitive differences in, 95-96 assessment, 416
short-term memory, 91 and depression, 412-414
pathological memory aging, 89-90 use of serotonin in, 413
Mental retardation, 323-345 psychophysics of, 415-416
and caregiving, 339-342 treatment, 414, 416-423
and dementia, 334 behavioral techniques, 418-419
and depression, 334 biofeedback,421-422
diagnosis and assessment, 324-331 cognitive-behavioral techniques, 419-420
adaptive behavior, 326-327 exercise, 421
behavior problems, 330 hypnosis, 422-423
cognitive functioning, 325-326 pharmacological control, 416-418
physical health, 327-330 relaxation techniques, 420
residential services for, 343-344 stress-inoculation therapy, 420
and retirement, 344-345 transcutaneous electrical nerve stimula-
and service delivery, 342-343 tion (TENS), 423
572 Index
Parkinson's disease, 119-120 of dimensional disorders, 502-504

Penile-brachial index (PBI), 263 substance abuse disorders, 503-504
Penn State Worry Questionnaire (PSWQ), 227, of mental disorders, 498-499
229 risk factors, 496
Personality Diagnostic Questionnaire-IV, 312 strategies for prevention. 497-498
Personality disorders, 301-322 Prostate specific antigen (PSA) levels, 265
assessment, 309-314 Psychoanalytic theory, 29-48
Coolidge Axis II Inventory (CATI), 311 adult development and. 34-35
Millon Clinical Personality Inventory lifecycle perspective, 35-45
(MCMI), 310-311 cognitive dimension. 40-41
Minnesota Multiphasic Inventory (MMPI), developmental lines, 36
309-310 moral dimension, 42-43
definition of, 301-303 narcissism, 44-45
diagnosis, 306-390 object-relations dimension, 41
DSM-IV personality disorders, 303-306 psychosexual dimension, 37-38
treatment, 314-317 psychosocial dimension. 38-40
Physical activity, 523-549 work identity. 39
actigraphy, 527-528 structural dimension. 41-42
circadian rhythms and, 542-547 transitional objects, 43-44
aging effects on, 543-544 mourning, 45-48
dementia and, 544-545 and melancholia, 46
depression and, 545 psychoanalytic models, 30-34
sleep and, 545-546 developmental theory, 32-34
sundowning and, 546-547 modern structural theory, 32
and disability, 525-528 object-relations theory. 31
hypokinetic disease, 525-526 self psychology, 30-31
exercise, 529-532 Psychogeriatric Assessment and Treatment in
adherence to, 535-536 City Housing (PATCH), 14
and anxiety, 534
and cognition, 534-535 Relapse Prevention (RP) model of addictive be-
and depression, 532-533 havior,66
and disease risk, 529-530 Retirement, 383-407
and life extension, 531-532 compulsory retirement, 389-391
and physical health, 530-531 definition of, 384-385
and recovery, 532 financial preparation for, 391-392
life-style, 526 and gender, 388-389
nocturnal activity, 536-542 and health, 394-397
sleep, 536-542 historical aspects, 386-387
disorders of, 539-542 occupational variables in, 393-394
apnea, 540 phases of, 385
arthritis and, 541-542 process approach to, 385
insomnia, 539-540 recent changes associated with, 406-407
Parkinson's disease and, 542 theories of, 397-405
restless legs and, 541 activity theory, 398-401
sleep-onset spectrum, 537-538 congruence theory, 402-403
personality variables and, 524-525 continuity theory, 401-402
Pick's disease, 120-121 developmental theory, 403-404
Pittsburgh Sleep Quality Index, 283 disengagement theory, 397-398
Post-traumatic stress disorder (PTSD), 218 personality theories, 405
Pre-Sleep Arousal Scale, 283 stress and coping theory, 404-405
Prevention, 495-504 and typology ofretirement, 387-388
of categorical disorders, 499-502
delirium, 501-502 San Francisco Geriatric Screening Project,
dementia, 499-501 10
mood disorders, 502 Schedule for Affective Disorders and Schizo-
clinical logic of, 496-497 phrenia (SADS), 202,472
definition of, 495-496 Schizophrenia, 173-194
Index 573
age and onset. 174-178 insomnia. 275-276

early-onset. 175-176 other sleep disorders. 276-277
gender. 178-179 Smoking. 358-361
late-onset. 177-178 cessation, 360
current conceptualization. 173-174 physiological difficulties. associated with.
outcome variables. 179-183 358-361
cohort, 179-181 Social Security. 20-24. 386
comorbidity, 182-183 Federal Insurance Contributions Act (FICA).
family, 181 20
medication. 181-182 and Health Maintenance Organizations.
biopsychosocial treatment model, 183-188 (HMOs). 23
biological, 184-185 Medicare and Medicaid. 21-22
psychosocial, 186-188 Social Security Amendments of 1954. 21
stress-vulnerability model, 186 Supplemental Security Income (SSI). 22
Sexual behavior. 239-268 Spielberger State Trait Anxiety Inventory
aging and. 239-241 (STAll. 219, 226. 227, 233,
biological factors and. 250-251 283
cohort effects on, 241-242 Spinal cord injuries, 371
of established partners, 242-245 Stanford-Binet Intelligence Scale: Fourth Edi-
health and, 248-250 tion.326
non-intercourse sexual activities, 245-247 Stress, 352-356
masturbation, 247-248 chronic illness and. 354
socio-economic status and. 248-250 in older versus younger adults. 352-353
Sexual dysfunction. 251-268 Structured Clinical Interview for DSM-III-R
assessment. 262-264 (SCID), 225. 472
etiology, 257-262 Structured Clinical Interview DSM-IV
prevalence. 251-256 (SCID-Ill. 202. 312
sexual satisfaction and. 256-257 Structured Clinical Interview-Nonpatient ver-
treatment. 264-267 sion (SCID-NP), 472
Sleep Behavior Self-Rating Scale, 283 Structured Interview for DSM-IV Personality
Sleep disturbances. 273-299 (SPID-IV). 312
assessment, 280 Structured Interview for Sleep Disorders, 281
behavioral, 283-284 Substance abuse disorders. 147-172
sleep laboratory evaluation. 283-284 age-related issues. 147-149, 154
clinical history. 281-282 alcohol in. 151-154
psychological. 282-283 diagnosis. 154-156
self-monitoring. 282 illicit drugs in, 149
clinical implications. 294-295 prescribed and non-prescribed psychoactive
drug-dependent insomnia. 292 drugs in. 150-151
etiology. 278-280 prevention. 165-166
behavioral factors. 180 tobacco in. 149
circadian factors. 280 treatment. 156-165
medical factors. 278-279 behavioral. 160-161
psychological factors. 279-280 community outreach. 162
prevalence. 273-274 detoxification. 158
treatment, 284-295 family therapy. 162-163
cognitive therapy, 290-291 group therapy, 161-162
education, 284-285 patient-treatment matching, 163-165
pharmacotherapy, 291 psychosocial therapy. 158-160
relaxation. 289-290 self-help. 163
sleep restriction. 288-289 Substance-Induced Persisting Dementia,
stimulus control, 285-288 124-125
with dementia. 292-293 Successful aging, 97-98
types. 274-278 Suicide, 81-83
and dementia. 277-278
and depression. 277 Tardive dyskinesia, 181-182
changes in sleep patterns, 274-275 Treatment adherence. 367-371
574 Index
Tremors, behavioral medicine interventions Vacuum construction device (VCD), 265

for, 364-365 Vascular dementia, 116-117
Type A Behavior, 357-358 Vineland Adaptive Behavior Scale, 326
Visual Analog Scale (VAS), 416
United States
Federal policy in, 19-27 Wechsler Adult Intelligence Scale-Revised
Legislative issues, 19-24 (WAIS-R), 326
US Department of Health and Human Services' White House Conference on Aging (WHCoA),
Task Force on Aging Research, 10
14
University of Minnesota Center for Residential Zung Self-Rating Anxiety Scale (SAS), 226
and Community Services Zung Self-Rating Depression Scale (SRS). 202
(CRCS), 329

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Handbook of

ADULT DEVELOPMENT, THERAPY, AND CULTURE

THE AMERICAN FATHER

THE DEVELOPMENT OF LOGIC IN ADULTHOOD

HANDBOOK OF AGING AND MENTAL HEALTH

HANDBOOK OF CLINICAL GEROPSYCHOLOGY

HANDBOOK OF PAIN AND AGING

HUMAN DEVELOPMENT IN ADULTHOOD

Springer Science+Business Media, LLC

Handbook of c l i n i c a l geropsycho logy / e d i t e d by Michel Hersen and

ISBN 978-1-4899-0132-3 ISBN 978-1-4899-0130-9 (eBook)

© Springer Science+Business Media New York 1998

RONALD D. ADELMAN, Division of Geriatrics and Gerontology, New York Hospi-

PATRICIA A. AREAN, Department of Psychiatry, University of California-San Fran-

J. GAYLE BECK, Department of Psychology, State University of New York, Buffalo,

STEPHEN J. BARTELS, Department of Psychiatry and Community and Family Med-

GARY R. BIRCHLER, Department of Psychiatry, School of Medicine, University of

FRANCE C. BLAIS, Ecole de Psychologie, Universite Laval, Cite Universitaire,

TONY CELLUCCI, Department of Psychology, Francis Marion University, Florence,

KATIE E. CHERRY, Department of Psychology, Louisiana State University, Baton

ANTONIA CHRONOPOLOUS, Center for Psychological Studies, Nova Southeastern

JOAN M. COOK, Center for Psychological Studies, Nova Southeastern University,

WILLIAM S. SHAW, Department of Psychiatry, School of Medicine, University of

Clinical psychology is a relatively young profession, with its major growth

We anticipate that this book will be of interest to professionals and stu-

PART I. GENERAL ISSUES

PART II. PSYCHOPATHOLOGY, ASSESSMENT. AND TREATMENT

13. Sleep Disturbances in Late Life 273

PART III. SPECIAL ISSUES

17. Health and Well-Being in Retirement: A Summary of Theories

A review of the historical perspectives of geropsychology reveals a remarkable

searchers and clinicians examining significant problems, more educational pro-

As far back as ancient times, philosophers have discussed unique features

Years 1835 to 1918

Years 1919 to 1946

Although largely ignored by fellow researchers, Foster and Taylor (1920)

In the clinical domain, Abraham (1919/1927) was the first psychoanalyst to

Years 1947 to the Present

The International Association of Gerontology (lAG) was established in

at approximately the same time on subjects differing in chronological age. Re-

Table 1-1. List of Current Journals in Geropsychology

Journals of Gerontology 1946

particular, the discrimination of diagnostic procedures in assessing subtypes

ACKNOWLEDGMENT. We thank George Neiderehe for his comments on an

CONTINIDNG POLICY AND

knowledge about the availability of services; inaccessibility due to a general lack

The financing of long-term nursing home care is a continuing unresolved

psychoanalytic thought and to establish a conceptual framework for the dis-

In formulating a psychoanalytic approach to geropsychology, it is impor-

Psychology of the Self

Heinz Kohut (1971, 1977), in a series of influential publications, laid the

Object Relations Theory

A second major advance within psychoanalytic theory is modern object re-

Modern Structural Theory

A third major dimension in psychoanalysis has been modern structuraJ the-

From the perspective of modern structural theory, important questions

A fourth and increasingly popular major model in psychoanalysis is a dy-

salient aspects of psychological structure and functioning are initiated in and

idiographic and nomothetic methodologies, while providing a context from

Traditionally, psychoanalysis has viewed adulthood as the endpoint of de-

Psychoanalysts have traditionally conceptualized personality development

MULTIPLE DIMENSIONS OF DEVELOPMENT